Breast Health Problem Course Pack - ROJoson

THE BREAST
HEALTH PROBLEM
BREAST DISORDERS
AN INSTRUCTIONAL PROGRAM FOR
PRIMARY HEALTH CARE PHYSICIANS
DESIGNED FOR:
PROBLEM-BASED LEARNING
COMPETENCY-BASED LEARNING
IN- AND OFF- CAMPUS LEARNING
Author:
Reynaldo O. Joson, MD, MHPEd, MS Surg

1999;2000
The Breast Health Problem-Breast Disorders
Content
Title
Content ............................................................................................................................ A
About the Author ............................................................................................................. B
Preface ............................................................................................................................ C
The Course Pack - Content and How to Use ...................................................................... D
Folder 1: Instructional Design ........................................................................................... I
Backgrounder of Design for University of the Philippines College of Medicine .... IA

Instructional Design ............................................................................................. IB
Folder 2: Hypothetical and Actual Patient Management ..................................................... II
Patient with a Breast Lump ................................................................................... IIA

Patient with Breast Pain ........................................................................................ IIB
Patient with Nipple Discharge ............................................................................... IIC
Patients with Various Complaints on the Breast .................................................... IID
Folder 3: Problem-based Learning Issues - Form ................................................................ III
Folder 4: Learning Objectives ............................................................................................ IV
General Learning Objectives ................................................................................ IVA

Clinical Competencies ......................................................................................... IVB
Biological Foundation and Basis of Clinical Management ................................... IVC
Folder 5: Learning Resource Materials and References ..................................................... V
List of Recommended References ........................................................................ VA
Learning Resource Materials

The Breast Health Issues and Problems-Breast Cancer (R.O. Joson)
Practical Mammopathology in Medical Practice (R.O. Joson)
Protocol on Breast Cancer, Division of Breast Surgery,
Department of Surgery, Philippine General Hospital
Manual on the Prevention and Control of Common Cancers, WHO
Regional Publications - Western Pacific Series No. 20, 1998
1993 Philippine Cancer Facts and Estimates,
Philippine Cancer Society, 1993
Cancer Treatment Guidelines, Philippine College of Surgeons,
Scientific Publication No.6, 1994
A1
The Breast Health Problem-Breast Disorders
Content
Folder 6: Evaluation ......................................................................................................... VI
Pretest I
Pretest II
Folder 7: Details and Format ............................................................................................ VII
Write-ups
Primary Health Care Physician ............................................................. VIIA

Problem-based Learning in Medicine ................................................... VIIB
Guidelines and Format

Overview and Personal Perspective ....................................................... VIIC
Public Health Education ........................................................................ VIID
Community Health Management ........................................................... VIIE
Case Presentation and Discussion .......................................................... VIIF
Hypothetical Patient Management ......................................................... VIIG
Psychosocial Issues ............................................................................... VIIH
Bioethical Issues ................................................................................... VII-I
Medicolegal Issues ................................................................................ VIIJ
Research Issues ..................................................................................... VIIK
Glossary ................................................................................................ VIIL
Self-Evaluation ..................................................................................... VIIM
Presentation in a Symposium ................................................................ VIIN
A2
About the Author
Present Academic Positions
Dr. Reynaldo O. Joson is presently a permanent professor at the Department of Surgery of the University of
the Philippines, College of Medicine.
He is at the same time an affiliate associate professor of the University of the Philippines Open University
as well as a faculty in the University of the Philippines College of Public Health.
He is currently the Chief of the Division of Head and Neck, Breast, Esophagus, and Soft Tissue Surgery at
the Philippine General Hospital.
Academic Degrees
He obtained his Doctor of Medicine from the University of the Philippines College of Medicine in 1974;
his Master in Hospital Administration from the UP College of Public Health in 1991; his Master in Health
Profession Education from the UP National Teachers Training Center for Health Profession in 1993; his Master of
Science in Clinical Medicine (General Surgery) from the UP College of Medicine in 1998.
His finished his residency in General Surgery at the Philippine General Hospital in 1981 after which he
became a Diplomate of the Philippine Board of Surgery.
Education for Health Development in the Philippines
One of his missions in life is to contribute to the health development in the Philippines through education.
This mission started in 1990 when, as Director of the UPCM Postgraduate Institute of Medicine, he designed a
structured Department of Health-UPCM Postgraduate Circuit Courses in four provincial hospitals in the Philippines
(Ilagan, Isabela in Luzon; Aklan in the Visayas; and Koronadal, South Cotobato and Oroquieta, Misamis Occidental
in Mindanao).
He then went on to develop a structured general surgery training program using a distance education mode
from 1991 to 1994 in Zamboanga City Medical Center. With this program, he added 7 trained general surgeons to
the pool of 2 that served the 3 million population of Western Mindanao.
In 1994, he helped established the Zamboanga Medical School Foundation. He helped designed a
community-oriented, competency-based, and problem-based learning medical curriculum for the school. This
curriculum was adopted by a medical school in Legazpi, Albay in 1995 and by another medical school in Cebu in
1996.
He is presently preoccupied with the full development of this curriculum as well as designing a telehealth
program.
Hospital Administration
He is currently an assistant medical director at the Manila Doctors Hospital in charge of its quality
assurance program.
B1
Writings
He started writing books, primers, self-instructional programs, and course packs in medicine, surgery,
hospital administration, and medical education in 1985. As of December of 1998, he has about 20 finished products.
Family
Contact Numbers
Dr. Reynaldo O. Josons email address is rjoson@pacific.net.ph

His telephone number is 523-2774.
R.O. Josons Website (started in 1999)
Theme: Education for Health Development in the Philippines

http://web.pacific.net.ph/~rjoson
B2
Preface
Dear Learner,
Mabuhay!
Welcome to a learning experience in becoming a health professional.
This program has been especially designed with you, the learner, and the principles of effective teaching
and learning in mind.
As you go through this learning program, please bear in mind the following:
1. I am treating you as an adult learner which
1.1 Assumes you have learning aspirations and expectations and therefore, are
motivated;
1.2 Gives you the privilege to use other learning strategies in achieving the objectives in
this program;
1.3 Welcomes you to go beyond the learning package as you so desire; and
1.4 Expects discipline, honesty, and maturity in fulfilling your learning activities.
2. We shall define learning as a positive observable change (for the better or improvement) in
human behavior, disposition, attitude, performance, or capability which persists over a
long period of time.
3. Active learning strategies and activities will be utilized as much as possible.
4. The program will contain learning materials which I think will be relevant to your being an
effective, efficient, and humane health professional.
5. The ultimate goal of the learning program is to produce health professionals who will
contribute to the health development in the Philippines.
6. When I made this program, I tried my best to facilitate your learning. Bear in mind, however,
that I am not infallible. Thus, analyze carefully everything in this program. Dont
hesitate to offer disagreements and constructive criticisms for own learning and for the
improvement of the program.
Best wishes for a fruitful learning with the help of this program.
Reynaldo O. Joson, MD, MHPEd, MHA, MS Surg

1999; 2000
The Course Pack

Content and How to Use
Content
The Course Pack on BREAST HEALTH PROBLEM - BREAST DISORDERS consists of seven (7)
folders:
Folder 1: Instructional Design

Folder 2: Hypothetical and Actual Patient Management
Folder 3: Problem-based Learning Issues
Folder 4: Learning Objectives
Folder 5: Learning Resource Materials
Folder 6: Evaluation
Folder 7: Details and Formats
Folder 1: Instructional Design

This folder contains the course plan.
Folder 2: Hypothetical and Actual Patient Management

This folder contains hypothetical patient management exercises which in turn consist of
sequential patient management cases and case studies.
It also contains an instructional plan on Actual Patient Management.
Folder 3: Problem-based Learning Issues

This folder contains the instructions and a form on which a student can write down problem-
based learning issues.
Folder 4: Learning Objectives

This folder contains general and specific learning objectives of the course.
Folder 5: Learning Resource Materials

This folder contains a list of recommended learning resource materials and selected and
prepared manuscripts.
Folder 6: Evaluation
This folder contains test blueprints and pretest examinations.
Folder 7: Details and Formats

This folder contains details and formats of learning and evaluating activities.
D1
The Course Pack

How to Use
Initial Steps:
Start by reading Folder 1 on Instructional Design.
For details on specific learning and evaluating activities encountered in Folder 1,

refer to Folder 7 on Details and Formats.
Then, scan the rest of the Folders (2-7).
Subsequent Steps:
This consists of the study and learning proper.
Start with the

Overview and Personal Perspective on the BREAST HEALTH PROBLEM - BREAST
DISORDERS. (see Folder 7 for the guidelines.)
Note down learning issues. Use the form provided in Folder 3.
Take note that a formal report is needed for purposes of presentation in the symposium
and evaluation.
Then tackle the Pretest examinations.

Take note that 50% of the questions in Posttest written examinations will be derived
from the Pretest.
Take note also that the Pretest gives a guide on where to focus when studying the course.
Studying the Pretest can also facilitate discussion in the
Hypothetical and Actual Patient Management.
Then tackle the Hypothetical and subsequently, the Actual Patient Management.
Take note that the exercises on Hypothetical and Actual Patient Management are
useful in preparing for the
written examinations
oral-practical examinations
project on case presentation and discussion
Overall Advice:
During the study proper, be constantly guided by the instructional design, especially the learning
objectives, which shall serve as the steering wheel in whatever that should be done in the course. This includes the
evaluation.
Reynaldo O. Joson, MD, MHPEd, MHA, MS Surg

1999;2000
D2
THE BREAST
HEALTH PROBLEM
BREAST DISORDER
Folder 1
Instructional Design
An Instructional Design on Breast Disorders

for the
University of the Philippines College of Medicine
A Backgrounder
Situational Analysis
I am to facilitate learning of the UP medical students on common surgical diseases of the breast.
These medical students will become primary health care physicians upon graduation.
The present UP medical curriculum provide the students opportunities to learn common surgical diseases of
the breast in the following years:
Classroom Learning Clinic Learning
Year IV 2 hours 2 hours preceptorial
Year V 2 hours Patient exposure
Year VI - Preceptorial
Year VII- Patient exposure
As the designated first facilitator in Year IV, I decided that I should lay down the foundation for all
subsequent teaching-learning opportunities.
The big question is:
How do I lay down the foundation for the teaching-learning of common surgical
diseases of the breast given the following scenarios:
2-hour allotment of classroom setting of teaching-learning
160 students
Terminal Competencies Expected of Graduates
First, I decided to spell out the competencies expected of the graduates who are going to be primary health
care physicians as far as management of breast problem is concerned.
The breast problem consists primarily of three types:
1. Breast disorders
2. Breast feeding problem
3. Breast sexuality problem
Since the breast feeding and sexuality problem will be tackled in other departments like pediatrics,
obstetrics and gynecology, and behavioral medicine, I decided to focus on breast disorders, both surgical and
nonsurgical ones. Learning common surgical diseases of the breast requires the simultaneous learning of
nonsurgical diseases.
IA1
Thus, the general learning objectives as far as breast disorders is concerned are the following:
At the end of the course, the primary health care physician-graduate must be able to:
1. Write an overview and a personal perspective on BREAST DISORDERS

in general and BREAST CANCER in particular as a global, national,
and local health problem.
2. Manage any patient with a BREAST DISORDER.
2.1 Demonstrate skills in:

2.1.1 Establishing rapport
2.1.2 Clinical diagnostic process
2.1.3 Paraclinical diagnostic process
2.1.4 Treatment process
2.1.5 Giving advice
2.1.6 Making referrals
2.2 Demonstrate qualities of an effective, efficient, and humane

physician.
2.3 Discuss/explain the biological foundation and basis of the

clinical management of a patient with a BREAST DISORDER.
3. Discuss the following issues in a patient with a BREAST DISORDER.

3.1 Clinical management issues
3.2 Psychological or behavioral issues
3.3 Bioethical issues
3.4 Medicolegal issues
4. Conduct a public health education on:

4.1 Prevention of MASTITIS
4.2 Early detection of BREAST CANCER
5. Conduct a research activity on BREAST DISORDERS.
6. Formulate a community health plan on the BREAST CANCER

PROBLEM.
7. Pass an examination on the BREAST DISORDER.
IA2
Learning Strategies
After formulating the general learning objectives or terminal competencies expected of the primary health
care physicians, I then decided on the best possible learning strategies:
1. Problem-based learning
2. Independent study
3. Discussion
4. Projects
5. Actual patient contact
6. Demonstration-return demonstration
Evaluation Methods
To complete the curriculum on breast disorder, I formulated the methods of evaluation based on the
learning objectives, namely:
1. Written examinations
2. Oral-practical examinations
3. Projects
Timetable and Scheme on Learning Objectives
As mentioned above, the present UP medical curriculum allows opportunities for students to learn breast
disorders from Year IV to VII. Come to think of it, they also study breast disorders in their anatomy, physiology,
and pathology subjects starting Year III.
Since I have to lay down the foundation in Year IV, I decided on the following timetable and scheme for
the learning objectives:
General Learning Objectives Year IV Year V Year VI Year VII

Overview and Perspective F M M M
Public Health Education F M M M
Community Health Management F M M M
Individual Health Management F M M M
Psychosocial Issues F M M M
Bioethical Issues F M M M
Medicolegal Issues F M M M
Research Issues F M M M
Examination / / / /
F - Foundation; M - Mastery
IA3
Specific Teaching-Learning Plan in Year IV
Alloted 2 hours for an initial formal classroom interaction between myself as the facilitator and the
students, with the latter having opportunities to be exposed to breast patients and to do independent study, I decided
on the following:
1. Prepare an instructional manual which the students can use as a guide.
2. Ask the students to read the instructional manual before class.
3. In class, focus discussion on Overview and Individual Health Management.
4. After class, ask the students to do projects on the learning objectives as well as prepare for the
examination.
5. Look for and set time for the students to present their projects.
6. Set a date for the written examination.
7. The oral-practical examination will be done during the preceptorials.

1999;2000
IA4
THE BREAST
HEALTH PROBLEM
BREAST DISORDER
Folder 1
Instructional Design
An Instructional Design on Breast Disorders

for the
University of the Philippines College of Medicine
A Backgrounder
Situational Analysis
I am to facilitate learning of the UP medical students on common surgical diseases of the breast.
These medical students will become primary health care physicians upon graduation.
The present UP medical curriculum provide the students opportunities to learn common surgical diseases of
the breast in the following years:
Classroom Learning Clinic Learning
Year IV 2 hours 2 hours preceptorial
Year V 2 hours Patient exposure
Year VI - Preceptorial
Year VII- Patient exposure
As the designated first facilitator in Year IV, I decided that I should lay down the foundation for all
subsequent teaching-learning opportunities.
The big question is:
How do I lay down the foundation for the teaching-learning of common surgical
diseases of the breast given the following scenarios:
2-hour allotment of classroom setting of teaching-learning
160 students
Terminal Competencies Expected of Graduates
First, I decided to spell out the competencies expected of the graduates who are going to be primary health
care physicians as far as management of breast problem is concerned.
The breast problem consists primarily of three types:
1. Breast disorders
2. Breast feeding problem
3. Breast sexuality problem
Since the breast feeding and sexuality problem will be tackled in other departments like pediatrics,
obstetrics and gynecology, and behavioral medicine, I decided to focus on breast disorders, both surgical and
nonsurgical ones. Learning common surgical diseases of the breast requires the simultaneous learning of
nonsurgical diseases.
IA1
Thus, the general learning objectives as far as breast disorders is concerned are the following:
At the end of the course, the primary health care physician-graduate must be able to:
1. Write an overview and a personal perspective on BREAST DISORDERS

in general and BREAST CANCER in particular as a global, national,
and local health problem.
2. Manage any patient with a BREAST DISORDER.
2.1 Demonstrate skills in:

2.1.5 Giving advice
2.2 Demonstrate qualities of an effective, efficient, and humane

physician.
2.3 Discuss/explain the biological foundation and basis of the
clinical management of a patient with a BREAST DISORDER.
3. Discuss the following issues in a patient with a BREAST DISORDER.

3.2 Psychological or behavioral issues
4. Conduct a public health education on:

5. Conduct a research activity on BREAST DISORDERS.
6. Formulate a community health plan on the BREAST CANCER

PROBLEM.
7. Pass an examination on the BREAST DISORDER.
IA2
Learning Strategies
After formulating the general learning objectives or terminal competencies expected of the primary health
care physicians, I then decided on the best possible learning strategies:
1. Problem-based learning
2. Independent study
3. Discussion
4. Projects
5. Actual patient contact
6. Demonstration-return demonstration
Evaluation Methods
To complete the curriculum on breast disorder, I formulated the methods of evaluation based on the
learning objectives, namely:
1. Written examinations
2. Oral-practical examinations
3. Projects
Timetable and Scheme on Learning Objectives
As mentioned above, the present UP medical curriculum allows opportunities for students to learn breast
disorders from Year IV to VII. Come to think of it, they also study breast disorders in their anatomy, physiology,
and pathology subjects starting Year III.
Since I have to lay down the foundation in Year IV, I decided on the following timetable and scheme for
the learning objectives:
General Learning Objectives Year IV Year V Year VI Year VII
Overview and Perspective F M M M
Public Health Education F M M M
Community Health Management F M M M
Individual Health Management F M M M
Psychosocial Issues F M M M
Bioethical Issues F M M M
Medicolegal Issues F M M M
Research Issues F M M M
Examination / / / /
F - Foundation; M - Mastery
IA3
Specific Teaching-Learning Plan in Year IV
Alloted 2 hours for an initial formal classroom interaction between myself as the facilitator and the
students, with the latter having opportunities to be exposed to breast patients and to do independent study, I decided
on the following:
1. Prepare an instructional manual which the students can use as a guide.
2. Ask the students to read the instructional manual before class.
3. In class, focus discussion on Overview and Individual Health Management.
4. After class, ask the students to do projects on the learning objectives as well as prepare for the
examination.
5. Look for and set time for the students to present their projects.
6. Set a date for the written examination.
7. The oral-practical examination will be done during the preceptorials.

1999;2000
IA4
THE BREAST
HEALTH PROBLEM
BREAST DISORDER
FOLDER 2
HYPOTHETICAL AND ACTUAL

PATIENT
MANAGEMENT
BREAST HEALTH PROBLEM - BREAST DISORDER
I. Hypothetical Patient Management

Sequential Patient Management - 3
Case Studies - 3
Sequential Patient Management
Chief Complaints
1. Breast lump
2. Breast pain
3. Nipple discharge
Case Studies (Based on the above Chief Complaints)

(See Details and Formats on Hypothetical Health Management)
II. Actual Patient Management (with case presentation and discussion)

Mininum of 2 patients in the entire course
Priorities:
Breast lump
Breast pain
(See Details and Formats on Case Presentation and Discussion)
II1
BREAST HEALTH PROBLEM- BREAST DISORDER
Chief Complaints Clinical Entities
1. Breast lump Fibroadenoma

Breast cancer
Macrocyst
Phyllodes tumor
Galactocoele
2. Breast pain Fibrocystic changes

Mastitis
3. Nipple discharge Intraductal papilloma
Fibrocystic changes
Galactorrhea
II2
INDIVIDUAL HEALTH MANAGEMENT

HYPOTHETICAL PATIENT MANAGEMENT
SEQUENTIAL PATIENT MANAGEMENT / CASE STUDY
BREAST LUMP
Trigger 1
Patient with complaint of Breast Lump

Questions:
1. What is a Breast Lump?

2. What are the possible causes of a Breast Lump?
Organs/tissues involved General condition/disorder Specific condition/disease
(e.g. trauma, cancer, infection)
___________________ __________________________ _____________________
___________________ __________________________ _____________________
___________________ __________________________ _____________________
3. What do you think are the more common/least common general and specific
condition causing a breast lump?
General condition/disorder Specific condition/disease

More common __________________________ _____________________
__________________________ _____________________
Least common __________________________ _____________________
__________________________ _____________________
4. Select one common general or specific condition and diagram the pathophysiology
leading to the breast lump.
IIA1
BREAST LUMP
Trigger 2
Pertinent history
30 years old, female
Chief complaint: Right breast lump
Noted 3 months ago
No associated symptoms
Physical examination:
Right breast lump
3 cm in its greatest diameter
well-defined border
solid in nature, not hard in consistency
movable, nontender
No axillary nodes
No associated distant mass
Questions:
1. What is your primary and secondary diagnosis?
Primary diagnosis: _____________________________________________
Secondary diagnosis: ___________________________________________
2. What are the bases for your primary and secondary diagnoses?
Demonstrate use of pattern recognition with pathophysiology and
prevalence.
Signs/Symptoms/Pathophysiology Prevalence data
Primary diagnosis
Secondary diagnosis
3. Do you need more data (sign/symptom) to firm up your primary and secondary
diagnoses?
If yes, what? How will it firm up your diagnosis?
[ Data asked for either not available or normal. Facilitator may supply other data.]
4. Do you need a paraclinical diagnostic procedure?

If yes, why? If no, why?
Demonstrate use of
1. certainty/uncertainty of primary and secondary diagnoses
2. plan of management for primary and secondary diagnoses
3. others
5. If you need a paraclinical diagnostic procedure, what will you recommend? Why?
Give at least 3 options and then compare using benefit, risk, cost, and
availability factors. Then select one demonstrating priority on the primary
diagnosis. Shotgun policy is NOT acceptable.
Benefit Risk Cost Availability
Option 1
Option 2
Option 3
6. Suppose the patient agreed to your recommendation of the paraclinical diagnostic
procedure and suppose it was done.
What results will firm up your primary diagnosis?
What results will make you shift to your secondary diagnosis as the primary
diagnosis?
IIA2
BREAST LUMP
Trigger 3.
A paraclinical diagnostic procedure was done.
A needle evaluation and biopsy was done.

The result shows:
solid nature of the mass
gritty on needling
positive cells consistent with malignancy.
Questions (as applicable):
1. Examine the result of the paraclinical diagnostic procedure and then interpret.
Decide whether the result is informative or non-informative.
Informative, why? Non-informative, why?
2. After the paraclinical diagnostic procedure, what is now your primary and secondary
diagnosis? Why?
Demonstrate use of pattern recognition with pathophysiology and prevalence.
Diagnostic Procedure/Signs/Symptoms/Pathophysiology Prevalence data
Primary diagnosis
Secondary diagnosis
3. Do you need to firm up your diagnosis before you proceed to treatment?

If yes, how?
What data do you need?
History?
Physical exam?
Other diagnostic procedure?
Observation and monitoring?
[Data asked for either not available or normal. Facilitator may supply other data.]
4. What is your pretreatment primary and secondary diagnoses?
5. State the goals of treatment for your primary diagnosis?
6. Decide on a treatment modality after comparing the options based on benefit, risk,
cost, and availability factors.

Nonoperative
(Specific procedure in mind)
Operative
8. Describe the things need to be done during the pretreatment, intratreatment, and
posttreatment phase.
7. Decide how you would evaluate the results or outcome of your proposed treatment.
IIA3
BREAST LUMP
Trigger 4
The diagnosis of the patients health problem is
BREAST CANCER
Questions:
1. Advice the patient and relatives on the pathophysiology of the disease. Use diagram.
2. Advice the patient and relatives on screening of the disease.
3. Advice the patient and relatives on early detection of the disease.
BREAST LUMP
Trigger 5
A 50-year-old female presented with a breast lump noted 5 months prior to medical consultation. There
were no associated symptoms.
On physical examination, a left breast mass was noted which measured about 4 cm in its greatest diameter
and which was solid in nature, not hard in consistency, and nontender. There were no associated axillary nodes nor
distant masses.
A needle evaluation and aspiration biopsy was done.
Six months after the breast lump was noted, she was subjected to a modified radical mastectomy.
Adjuvant hormonal therapy was given postoperatively.
Three years postop, she started complaining of low back pain. After diagnostic procedures were done to
investigate the pain, she was subjected to a course of radiotherapy. This therapy relieved her from the pain.
Six months after the radiotherapy, she started complaining of dyspnea. A chest x-ray showed multiple
nodular densities and blunting of the left costophrenic sinus. A left tube thoracostomy was done which afforded
minimal relief.
Three months later, she died.

Questions:
1. Study the case and then decide on the primary and secondary diagnoses.
Give bases for your diagnoses using
pattern recognition with pathophysiology
prevalence
2. Study the case and then

2.1 Comment on the outcome of treatment.
Were the goals of treatment achieved? Yes, why? No, why?
2.2 Describe the prognosis after treatment.
Recurrence, survival, quality of life
Pathophysiology of the disease leading to physical disability and death
IIA4

BREAST PAIN
Trigger 1
Patient with complaint of Breast Pain
Questions:
1. What is Breast Pain?
2. What are the possible causes of Breast Pain?

___________________ __________________________ _____________________

___________________ __________________________ _____________________
___________________ __________________________ _____________________
condition causing a breast pain?

More common __________________________ _____________________
__________________________ _____________________
Least common __________________________ _____________________
__________________________ _____________________
leading to the breast pain.
IIB1
BREAST PAIN
Trigger 2
Pertinent history
Chief complaint: Right breast pain
Noted 3 months ago, on and off, no pattern
No dominant breast mass on both breasts but with nodular surface on the
right breast which was slightly tender
no erythema
No axillary nodes
No associated distant mass
Questions:

Primary diagnosis
Secondary diagnosis
diagnoses?

Demonstrate use of
3. others
Option 1
Option 2
Option 3
diagnosis?
IIB2
BREAST PAIN
Trigger 3.
A paraclinical diagnostic procedure in the form of monitoring-surveillance was done.
After 3 months of monitoring,

no dominant mass was found; breast surface was still nodular;
tender area in the right breast has improved; no erythema
no axillar nodes;
no distant mass.
diagnosis? Why?
Primary diagnosis
Secondary diagnosis

If yes, how?
History?
Physical exam?
Nonoperative
Operative
IIB3
BREAST PAIN
Trigger 4
FIBROCYSTIC CHANGES OF THE BREAST

Questions:
BREAST PAIN
Trigger 5
A 30-year-old female presented with breast pain noted one week prior to medical consultation. There were
no associated symptoms.
She gave birth to her second child one month prior to onset of the breast pain. She was an advocate of
breast feeding.
On physical examination, a left breast mass was noted which measured about 5 cm in its greatest diameter
and which was cystic in nature, fluctuant, tender with slight erythema on the overlying skin. There were no
associated axillary nodes nor distant masses.
An operative procedure was done which yielded yellowish liquid substance.
Two months after, the operative wound was completely healed.
She reported no recurrence of the same problem when she saw her physician five years after in a
mall.
Questions:
prevalence

IIB4
NIPPLE DISCHARGE
Trigger 1
Patient with complaint of Nipple Discharge

Questions:
1. What is Nipple Discharge?
2. What are the possible causes of Nipple Discharge?

___________________ __________________________ _____________________

___________________ __________________________ _____________________
___________________ __________________________ _____________________
condition causing a nipple discharge?

More common __________________________ _____________________
__________________________ _____________________
Least common __________________________ _____________________
__________________________ _____________________
leading to a nipple discharge.
IIC1
NIPPLE DISCHARGE
Trigger 2
Pertinent history
Chief complaint: Nipple discharge on the right breast
Noted 3 months ago, nonsanguinous, on and off, no pattern
Minimal serous nonsanguinous discharge from the right nipple on squeezing
No dominant breast mass on both breasts but with nodular surface on the
right breast which was slightly tender
no erythema
No axillary nodes; no associated distant mass
Questions:

prevalence.
Primary diagnosis
Secondary diagnosis
diagnoses?

Demonstrate use of
3. others
Option 1
Option 2
Option 3
diagnosis?
IIC2
NIPPLE DISCHARGE
Trigger 3.
A paraclinical diagnostic procedure in the form of monitoring-surveillance was done.
After 3 months of monitoring,
still with serous nonsanguinous nipple discharge on her right breast
no dominant mass was found; breast surface is still nodular;
tender area in the right breast has improved; no erythema
no axillar nodes; no distant mass.
diagnosis? Why?
Primary diagnosis
Secondary diagnosis

If yes, how?
History?
Physical exam?
Nonoperative
Operative
IIC3
NIPPLE DISCHARGE
Trigger 4
FIBROCYSTIC CHANGES OF THE BREAST

Questions:
NIPPLE DISCHARGE
Trigger 5
A 30-year-old female presented with sanguinous nipple discharge on her right breast noted one week prior
to medical consultation. There were no associated symptoms.
She was not pregnant nor lactating at time of onset of nipple discharge.
On physical examination, sanguinous discharge was noted on her right nipple upon squeezing.
There was no palpable breast mass nor tenderness. There was no associated axillary lymph node nor distant mass.
Monitoring and surveillance were done.
After 3 years, she decided to undergo an operation because she felt uncomfortable with the persistence of
the sanguinous nipple discharge.
On operation, the duct where the discharge was coming from was identified and then excised. No mass
was noted within the duct.
One year after, the sanguinous discharge on the right nipple recurred.
She was adviced monitoring and surveillance.
Five years after the operation, the sanguinous nipple discharge was still present. She chose to live with it
under medical surveillance.
Questions:
prevalence
IIC4

Given a set of clinical data of a patient with a breast problem, give the primary clinical diagnosis by selecting from
the list provided. The item in the list of clinical diagnosis may be used more than once.
A. Breast cancer H. Pagets disease of the nipple

B. Fibroadenoma I. Virginal hypertrophy or macromastia
C. Macrocyst J. Gynecomastia
D. Galactocoele K. Fibrocystic changes
E. Phyllodes tumor L. Intraductal papilloma
F. Mastitis M. Tuberculosis of the breast
G. Breast abscess N. Inflammatory breast cancer
___ 1. 30 y.o. female with draining sinuses on one breast of one year duration. No definite breast mass,
just indurations. Positive ipsilateral axillary lymph nodes.
___ 2. 15 y.o. male with enlargement of one breast, slightly tender, no erythema, no warmth, no axillary
nodes.
___ 3. 45 y.o. male with enlargement of one breast, slightly tender, no erythema, no warmth, no axillary
nodes.
___ 4. 35 y.o. female with sanguinous nipple discharge on one breast. No palpable breast mass. No
axillary nodes.
___ 5. 45 y.o. female with nodular breast tissues, no definite breast mass, slightly tender, no erythema, no
warmth, no axillary nodes.
___ 6. 45 y.o. female with nipple-areolar erosions on one breast. No palpable breast mass. No axillary
nodes.
___ 7. 30 y.o. female with firm, solid, nontender, very movable well-defined breast mass on one side. No
axillary nodes.
___ 8. 30 y.o. female, lactating, with slightly tender breast mass noted recently, no erythema, no warmth,
no axillary node.
___ 9. 40 y.o. female, nonlactating, with multiple slightly tender breast masses on both breasts, no
erythema, no warmth, no axillary nodes.
___ 10. 40 y.o. female with hard mass with ill-defined border, not fixed to underlying nor overlying
structures. No axillary nodes.
___ 11. 40 y.o. female with erythema over one breast, tender, warm, with no definite mass.
___ 12. 20 y.o. female with well-defined movable masses, no axillary nodes.
___ 13. 55 y.o. female with bilateral breast masses, not fixed, slightly tender, no erythema, no warmth, no
axillary nodes.
IID1

A. Breast cancer H. Pagets disease of the nipple

B. Fibroadenoma I. Virginal hypertrophy or macromastia
C. Macrocyst J. Gynecomastia
D. Galactocoele K. Fibrocystic changes
E. Phyllodes tumor L. Intraductal papilloma
F. Mastitis M. Tuberculosis of the breast
G. Breast abscess N. Inflammatory breast cancer
___ 14. 30 y.o. female with a breast mass on one side with an ipsilateral axillary lymph node.
___ 15. 35 y.o. female with a breast mass, tender, with erythema, and warmth.
___ 16. 40 y.o. female with 10cm multinodular breast mass on one side, movable but fixed to overlying
skin, no axillary nodes.
___ 17. 40 y.o. female with one breast 3x the size of the other breast. No definite breast mass. No axillary
nodes.
___ 18. 45 y.o. male with hard mass, not fixed, no axillary nodes.
___ 19. 30 y.o. female with fungating mass on one breast, no axillary nodes.
___ 20. 50 y.o. female with no definite breast mass, but with erythema, no tenderness, no warmth, no
axillary nodes.
___ 21. 80 y.o. female with breast mass on one side with ill-defined border, no axillary nodes.
___ 22. 60 y.o. female with a breast mass on one side, depressible, no axillary nodes.
___ 23. 35 y.o. female with well-defined movable mass, nontender, solid, no axillary nodes.
___ 24. 30 y.o. female with an area of prominence, slightly tender, no erythema, no warmth, no axillary
nodes.
___ 25. 65 y.o. male with fixed mass, no axillary nodes.

IID2
THE BREAST
HEALTH PROBLEM
BREAST DISORDER
FOLDER 3
PROBLEM-BASED
LEARNING ISSUES
Problem-based Learning Issues
Instructions
Given hypothetical and actual patients, pretest questions and any kind of BREAST
HEALTH PROBLEM (BREAST DISORDER) to solve, list down deficiencies and
uncertainties in competences as learning issues and decide on a specific learning plan. Use
the form below.
Trigger* Learning Issues Learning Plan**

*Hypothetical Patient Management (HPM)
Actual Patient Management (APM)
Pretest
**Reading - what and which books, journals

Asking - whom, where, when
Doing - what, where, when
THE BREAST
HEALTH PROBLEM
BREAST DISORDER
FOLDER 4
LEARNING OBJECTIVES
BREAST DISORDERS
GENERAL LEARNING OBJECTIVES
At the end of the course, the student must be able to:
1. Write an overview and a personal perspective on BREAST DISORDERS in general and

BREAST CANCER in particular, as a global, national and local health problem.
2. Manage any patient presenting with a BREAST DISORDER.
2.1 Demonstrate skills in

2.1.5 Giving advice
2.2 Demonstrate qualities of an effective, efficient, and humane physician.

2.3 Discuss/explain the biological foundation and basis of the clinical management of a
patient with a BREAST DISORDER.
3. Discuss the following issues on BREAST DISORDERS.

3.2 Psychosocial or behavioral issues
4. Conduct a public health education program on the

5. Perform a research activity on BREAST DISORDERS.

6. Formulate a community health plan on the BREAST CANCER PROBLEM .
7. Pass examinations on BREAST DISORDERS.
IVA
BREAST DISORDERS
CLINICAL COMPETENCY
General Clinical Competencies:
A primary health care physician must be able to manage any patient with a BREAST DISORDER.
He must be able to:
1. Outline the goals in the management.
2. Demonstrate skills in:
2.1 Establishing rapport.

2.2 Clinical diagnostic process.
2.3 Paraclinical diagnostic process.
2.4 Treatment process
2.5 Giving advice.
2.6 Making referrals.
3. Demonstrate qualities of an effective, efficient, and humane physician.
Specific clinical competencies:
Given actual and simulated patients with a BREAST DISORDER, a primary health care physician must be
able to:
1. Diagnose the presence of the BREAST DISORDER (and its kinds and causes) through
interviewing and examining.
2. Decide on how to stop the BREAST DISORDER process, if possible.
3. Determine the severity of the BREAST DISORDER and how it will affect management.
4. Determine indications for cardiopulmonary resuscitation. If indicated, perform.

5. Determine indications for ventilatory therapy (oxygen, endotracheal intubation,
tracheostomy). If indicated, prescribe.
6. Determine indications for intravenous fluid therapy. If indicated, prescribe the type of
fluids, amount, and rate of administration during the first 24 hours after decision.
7. Determine indications for blood therapy. If indicated, prescribe the type of blood,
amount, and rate of administration during the first 24 hours after decision.
8. Determine indications for analgesic therapy. If indicated, prescribe the type, dosage, and route
of administration.
IVB1
9. Determine indications for tetanus prophylaxis. If indicated, prescribe the type, dosage,
and route of administration.
10. Determine indications for antibiotic therapy. If indicated, prescribe the type, dosage,
and route of administration.
11. Determine indications for paraclinical diagnostic procedures. If indicated, advice on

selection.
12. Advice on treatment, on options, and selection..
13. Determine indications for hospitalization. If indicated, write an admitting order.
14. Determine indications for referrals. If indicated, write a letter of referral.
15. Prescribe an outpatient/clinic/home treatment.
16. Advice on prognosis and recovery.
17. Advice on preventive and promotive health measure.
18. Perform the following procedures:
1. Establish rapport with the patient and her relatives

2. Interview
3. Perform a physical examination
4. Perform cardiopulmonary resuscitation
5. Establish an intravenous line
6. Administer parenteral medications
7. Prescribe a drug
8. Write an admitting order
9. Write a letter of referral
10. Write a medical certificate
11. Fill up a death certificate
IVB2
BREAST DISORDERS
BIOLOGICAL FOUNDATION AND BASIS OF CLINICAL MANAGEMENT
General Learning Objectives:
A primary health care physician must be able to discuss/explain the biological foundation and
basis in the clinical management of a patient with BREAST DISORDER.
Enabling objectives:
A primary health care physician must be able to answer the questions and accomplish the tasks
listed below:
Epidemiology
1a. What is a BREAST DISORDER?

1b. How common are BREAST DISORDERS as a health problem in the community? Support
your answer.
Common/uncommon
Global -
National -
Local -
2a. What are the different types/causes of BREAST DISORDERS?

2b. What are the 2 more common types/causes of BREAST DISORDERS in the community?
3a. What type(s) of persons (based on age groups, occupations, behaviors, and other factors) are
at higher risk for BREAST DISORDERS?
3b. What type(s) of social environment (cultural practices, folk beliefs) predispose persons to
BREAST DISORDERS?
3c. What type(s) of occupations and physical environment predispose persons to BREAST
DISORDERS?
Pathophysiology
1. Make a diagram of a conceptual framework on the general pathophysiology of BREAST
DISORDERS.
1.1 Make a diagram of a conceptual framework on the pathophysiology of the
different types/causes of BREAST DISORDERS.
2. What systems, organs, tissues, and cells are usually involved in BREAST DISORDERS
(in general and in particular types)? Draw the organs involved.
3. What are the usual functions of the different systems, organs, tissues, and cells that are usually
involved in BREAST DISORDERS?
IVC1
4. What are the usual changes in structure that may occur after the different systems, organs,
tissues, and cells are involved in BREAST DISORDERS (in general and in particular
types)?
Usual Changes in Structure
(in general terms)
System
Organ
Tissue
Cell
5. What are the usual changes in structure that may occur after the different systems, organs,
tissues, and cells are involved in BREAST DISORDERS (in general and in particular
types)?
Usual Changes in Function
(in general terms)
System
Organ
Tissue
Cell
6. How does the human body respond to the BREAST DISORDERS, specifically, what are the
endocrine, metabolic, and psychologic responses?
7a. Name three possible outcomes that may happen after a person is involved in BREAST
DISORDERS (in general and in particular types) in the absence of a physicians
intervention.
7b. Name three possible outcomes that may happen after a person is involved in BREAST
DISORDERS (in general and in particular types) in the presence of a physicians
intervention.
7c. What are the usual causes of disability in patients with BREAST DISORDERS (in general
and in particular types)?
7d. What are the usual causes of death in patients with BREAST DISORDERS (in general
and in particular types)?
CAUSES
DISABILITY
DEATH
Diagnosis
1. What are the usual presenting signs and symptoms of patients with BREAST DISORDERS?
2. What are the paraclinical diagnostic procedures that are known to be done for patients with
BREAST DISORDERS (in general and in particular types)? If there are, name at least
three. Briefly describe how they are being done. Then, compare them in terms of
benefit- risk-cost-availability in the community. Identify an indication for each
procedure.
PCD1 PCD2 PCD3
BENEFIT
RISK
COST
AVAILABILITY
IVC2
Treatment
1a. What are the indications for nonoperative treatment in patients with BREAST DISORDERS?
1b. Name at least three forms of nonoperative treatment in patients with BREAST DISORDERS.
Briefly describe them and give an indication for each.
2a. What are the indications for operative treatment in patients with BREAST DISORDERS?
2b. Name at least three forms of operative treatment in patients with BREAST DISORDERS.
Briefly describe them and give an indication for each.
2c. For a particular BREAST DISORDER, enumerate at least three possible treatment procedures
or options (both operative and nonoperative). Then compare them in terms of benefit-
risk-cost-availability in the community.
T1 T2 T3
BENEFIT
RISK
COST
AVAILABILITY
Management Plan, Algorithm, or Protocol
1. Outline the goals in the management of patients with BREAST DISORDERS.
2. Write a plan, algorithm, or protocol illustrating the general steps in the management of
patients with BREAST DISORDERS in general.
3. Write a plan, algorithm, or protocol illustrating the general steps in the management of
patients with specific kinds of BREAST DISORDER.
Preventive and Promotive Health Program
1. Based on known risk factors, suggest ways to prevent BREAST DISORDERS.

2. Formulate (outline) a preventive and promotive health program on BREAST DISORDERS
for yourself.
3. Formulate (outline) a preventive and promotive health program on BREAST DISORDERS
for your community.
Identification of Issues
1. Identify at least one psychosocial factor that may promote occurrence of BREAST
DISORDERS or that may affect recovery of patients with BREAST DISORDERS.
2. Identify at least one bioethical issue that may be encountered in the management of patients
with BREAST DISORDERS.
3. Identify kinds/causes of BREAST DISORDERS that usually have legal implications and then
briefly describe the legal implications.
4. Identify at least one medicolegal issue that may be encountered in the management of patients
with BREAST DISORDERS.
5. Identify at least one personal research question in BREAST DISORDERS and briefly state the
reasons why you consider it as such.
IVC3
THE BREAST
HEALTH PROBLEM
BREAST DISORDER
FOLDER 5
LEARNING RESOURCE
MATERIALS AND REFERENCES
BREAST HEALTH PROBLEM - BREAST DISORDER

Recommended Reading Materials
Textbooks of
Anatomy
Physiology
Pathology
General Surgery
Oncology
Pharmacology
Journal articles on Breast Problem - Disorders
Internet
GSI Telehealth Program TeleBreast Program

(http://members.xoom.com/rjoson/gs1telebreast/telebreast.htm)
Medline (http://www.gateway.com)
American Cancer Society (http://www.acs.org)
Others:
1993 Philippine Cancer Facts and Estimates, Philippine Cancer Society, 1993
Cancer Treatment Guidelines, Philippine College of Surgeons,

Scientific Publication No. 6, 1994
Manual on the Prevention and Control of Common Cancers

WHO Regional Publications - Western Pacific Series No.20, 1998
R.O. Josons Writings

Breast Surgical Diseases
The Breast Health Issues and Problems - Breast Cancer
Management of a Surgical Patient (SIP, 1998;2000)
Protocol on Breast Cancer, Division of Breast Surgery, Department of Surgery,

Philippine General Hospital
Pictorials and Multimedia Learning Materials
Actual Patients with Breast Problem
Breast Problem Specialists
VA
The Breast Health Issues and Problems

Breast Cancer
Handout/Lecture for UPCM Year IV

1998;1999;2000
Reynaldo O. Joson, MD
The breast health issues and problems involve the young and the old and both the female and male gender
(Table 1).
Table 1. Breast Health Issues and Problems.
Female / Male
Newborn Congenital anomalies

Transient breast events
Witchs milk
Gynecomastia
Adolescence Developmental aberrations
Adult
Young Benign breast masses
Sexuality issues
Breast feeding issues
Middle age Cancer
Elderly Cancer
In the newborn, the issues consist primarily of 1) congenital anomalies such as accessory nipples and 2)
events like witchs milk and gynecomastia which are transient and related to maternal hormonal effect on the babies
breasts.
In the adolescence, the issues consist primarily of developmental aberrations such as asymmetric
hypertrophy or exaggerated hyperplasia of the breasts.
In the young adults, benign masses, breast-related sexuality issues and for the lactating mothers, breast-
feeding issues are the predominant concerns.
In the middle age and elderly people, breast cancer is the primary concern.
For our purpose, we will focus on the breast cancer issues and problems.
Prevalence and Incidence of Breast Cancer
Present statistics in the Philippines show that breast cancer ranks second on all cancers involving females
and males, second to lung cancer. Among the Filipino females, breast cancer is the most common followed by
cervical cancer. Male breast cancer occurs in a ratio of 1:100 female breast cancer.
Outside the Philippines, breast cancer is also very common. In North America, Northern Europe, and
Australia, it is second if the not first in the listing of cancer incidence by site.
The incidence of breast cancer in the Philippines (21.6/100,000) may not be as high as in North America
(110/100,000) and Europe (~100/100,000), but it appears to be the highest recorded in Asia (with the exception of
Jews in Israel).
The key point here is that breast cancer is very common, globally and in the Philippines.
Breast Cancer as a Public Health Problem in the Philippines
Its being the overall second most common cancer and the first most common cancer among women makes
breast cancer a significant public health problem in the Philippines.
The other major reasons are:
1. The fatality rate of breast cancer is high. Majority, if not all, patients with breast cancers
eventually die of the disease.
2. The specific cause of breast cancer is not known. Thus, there is no effective and efficient way
of prevention and foolproof way of treatment.
Other factors that make breast cancer a significant public health problem in the Philippines consist of the
following:
1. Late diagnosis and treatment

2. Unaffordable (expensive) treatment
3. Lack of state-of -the art technology in diagnosis and treatment of breast cancer
4. Lack of coordinated effort in the breast cancer control program
Of these 4 factors, the most important is the lack of coordinated effort in the breast cancer control program.
Such a program should try to reduce death and sufferings from breast cancer using the primary health care approach
(emphasizing on people empowerment). The Philippines has a Breast Cancer Control Program under the
Department of Health. It has yet to be fully implemented and sustained thereafter.
The Breast Cancer Control Program (BCCP) of the Philippines
The BCCP is under the Philippine Cancer Control Program of the Department of Health. It refers to the
implementation of a nationwide anti-breast cancer scheme, that is, public information and health education, case
findings (secondary prevention) and treatment (tertiary prevention) integrated into the community health structure
and equipped to control breast cancer in a systematic sustained manner.
The specific objectives of the BCCP are:
1. To inform or educate all women 30-60 years old on breast self-examination (BSE).
2. To detect the maximum number of early stage breast cancers by offering yearly breast
examination to all 30-60 years women attending a health institution.
3. To treat and/or rehabilitate all detected cases.
The program strategies of the BCCP consist of the following:
1. Full integration of the basic cancer control measures, i.e., public information and health
education, case finding and treatment, with the governments basic medical health
services and other non-governmental organizations through the primary health care
approach.
2. Operationalization of a bilateral referral system.
3. Making more intensive use of information, education, and communication activities.
4. Standardizing recording and reporting with built-in monitoring and evaluating system.
5. Establishment of regular and frequent supervision.
6. Adopting post-surgical adjuvant chemotherapy regimen for six months for all pre-menopausal
and hormonal receptor-negative post-menopausal patients as well as adjuvant hormonal
regimen for 2-5 years for hormonal receptor positive post-menopausal patients.
7. Provision of adequate logistical support for public health and hospital services.
8. Making available breast examination training programs, residency and postresidency training
programs, hospital services and anticancer drugs.
The BCCP is an attempt to address the breast cancer health problem in the Philippines. It utilizes the
concept of primary health care approach.
It is nice on paper. What is needed now is implementation and cooperative and participative efforts from
all concerned, from both health care providers and the people.
How do we contribute to the BCCP?
Lets equip ourselves with the know-how to advise people on

early detection of breast cancers
importance of early detection and treatment of breast cancers
diagnostic cues for breast cancers
diagnostic procedures for breast cancers
treatment for breast cancers
More important of all, lets be role-model in solving the breast health problem by practicing what we
preach or will advice to the people.
Types of Breast Cancers and Their Origin
Breast cancer can arise from the ductal element (ductal carcinoma), lobular or glandular element (lobular
carcinoma) or from the soft tissue element of the breast (sarcoma). Among the three, ductal carcinoma is most
common and breast sarcoma is least common.
Breast carcinomas (both ductal and lobular carcinomas) can either be non-infiltrating (in-situ) or infiltrating
(which has gone through the basement membrane of the cells). Infiltrating carcinomas represent a more advanced
stage of the cancer than the non-infiltrating ones, thus carrying a poorer prognosis. Usually, palpable breast
carcinomas are infiltrating whereas in-situ carcinomas are nonpalpable and usually discovered via a mammography.
There are various histologic types of ductal carcinomas such as medullary, tubular, and scirrhous but the
most common type at present is the nonspecified ductal carcinomas. Between infiltrating and non-infiltrating
carcinomas, with the advent of mammography, more and more non-infiltrating types are being seen. Overall,
however, the infiltrating types are still more common, signifying the later stage in which breast cancers are being
discovered.
Etiology and Risk Factors of Breast Cancers
The exact etiology is not known.
There are many interrelated factors that have been associated with an increased risk of developing breast
cancer. These include:
1. Previous history of breast cancer
2. Increasing age
Breast cancer is rare in women under 30, but the risk rises steadily with age.
3. First degree relative (mother, sister, or daughter) with breast cancer
4. Previous radiation to the breast
5. Nulliparity at age 40
6. First full-term pregnancy at age 35 or more
7. Early menarche (aged 12 or younger)
8. Late menopause (aged 50 or older)
9. History of primary cancer of the ovary or endometrium
10. Obesity in postmenopausal women
11. Evidence of specific genetic susceptibility (such as carriage of BRCA1 and BRCA2)
12. Hormone replacement therapy
These risk factors account for NO more than 30% of breast cancers.
Being FEMALE and GETTING OLDER are the two main risk factors in the development of breast cancer.
Female to male ratio in breast cancer prevalence: 100:1
Age:
Breast cancer is rare in women under 30.
More than 70% of all breast cancer occurs in women aged 50 and over.
AGE is the biggest risk factor, NOT FAMILY HISTORY.

In nine out of ten breast cancer cancer, there is NO family history.
The clinical applications consist of the following:
1. Virtually all women will have one or more risk factors for breast cancer. However, most risk factors are
at such a low level that they only partly explain the high frequency of the disease among women.
To date, knowledge about the risk factors has NOT translated into practical ways to prevent breast cancer.
The best opportunity for reducing the death rate from breast cancer is through EARLY DETECTIION.
2. Since the exact etiology is not known, there is said to be no effective and efficient ways of prevention
and foolproof way of treatment. The treatment presently being used target the cancer and not the cause of cancer.
Thus, with the cause not being removed, there is always the potential for recurrence of the cancer after the usual
treatment of surgery, radiotherapy, and chemotherapy.
At present, the only practical way to reduce the suffering and death from breast cancer is EARLY
DETECTION AND TREATMENT of the breast cancer. Early detection and treatment has been known to carry a
better prognosis compared to late detection and treatment.
Early Detection of Breast Cancer

1. Screening of persons at moderate to high risk of developing breast cancer
Females aged 30 and above, with no history of breast cancer, with no family history of
breast cancer
Breast self-examination (monthly)
Clinical breast examination (yearly)
Mammography
Starting at aged 50 (annually)
Females with a strong family history of breast cancer

Breast self-examination (monthly)
Clinical breast examination (biannually)
Mammography
Starting at aged 40 (annually)
Breast self-examination
To look for a lump.
If positive or suspected,
consult a breast specialist right away who will establish the diagnosis.
Clinical breast examination

To look for a lump.
establish the diagnosis.
Mammography
To look for microcalcifications or other radiologic signs that suggest the
presence the breast cancer.
consult a breast specialist who will try to establish the diagnosis.
2. Early evaluation of symptoms

Lump
Nipple discharge
Skin changes
Anything unusual on the breast
CONSULT A BREAST SPECIALIST RIGHT AWAY!
5
3. Public health education

Awareness of the importance of early detection and early treatment of breast cancer
Higher chances for longer survival with early detection and early treatment
Personal know-how in
doing breast self-examination
recognizing cues for breast cancer
making decision for early diagnosis and early treatment
Cues or Suspicious Signs of Breast Cancers in Patients with Breast Symptoms
Lump
Hard
Ill-defined border
Fixed to underlying and overlying structures
Skin dimpling and nipple retraction
Associated with bloody nipple discharge
Associated with lymph nodes
Nipple discharge
Bloody nipple discharge with a palpable mass
Skin changes
Dimpling
Nipple retraction
Ulcerations
Erosions in the nipple-areolar complex
Clinical Diagnostic Algorithm for Breast Mass
Look for signs of inflammation associated with the breast mass

Pus
Erythema
Tenderness
Warmth
Look for signs of malignancy

Signs of invasions
fixation
skin involvement
Signs of spread
axillary lymph nodes
distant areas
Other characteristics
Hard consistency
ill-defined border
Look for signs of benignity

cystic nature of the mass - containing fluid
well-defined border and very mobile
Breast Mass
|
Inflammatory --------------------------------------------------Noninflammatory
|
Malignant -------------------------------------------Nonmalignant
Signs of inflammations - YES ---> mastitis/breast abscess

- no
Signs of malignancy - YES ---> breast cancer

- no
Consider benign mass
especially if signs of benignity present
Diagnostic Procedures
Basic indication -
If there is a need for a more definitive diagnosis after interview and physical exam
to facilitate decision-making in treatment.
Procedures:
Biopsy - ultimate basis of diagnosis
Closed
Needle biopsy
Core biopsy
Open
Excision
Incision
Mammography
Ultrasound
Comparative analysis of diagnostic procedures used in decision-making:
Biopsy Most direct way Most invasive

to definitive
diagnosis
Mammography Indirect way

Needs biopsy
for supplement
Ultrasound Indirect way Least invasive

Needs biopsy
for supplement
Comparative analysis of biopsy procedures used in decision-making:
Needle Diagnostic Least invasive Lowest cost

yield acceptable
but lowest
compared to the
other two
Core
Open Highest yield Most invasive Highest cost
Basic indications for diagnostic procedures:
Biopsy
Want the direct way of diagnosing a breast mass
Mammography
Want to screen for multifocal nonpalpable cancers in the affected and in the
contralateral breast
Want to evaluate an indefinite breast lump found in physical examination
Ultrasound
Want to evaluate an indefinite breast lump found in physical examination
Treatment for Breast Cancers
Staging
using the TNM classification

T- tumor N- node M- metastasis
Stage 0 to IV
Uses:
Determining the extent of the disease
Helpful in guiding treatment
Helpful in prognostication
5-yr survival rate
Stage 0 - earliest stage best prognosis >90%
Stage I 90%
Stage II 70%
Stage III 10-15%
Stage IV - disseminated stage poorest prognosis <5%
Treatment modalities, forms and common usage
Locoregional
Surgery
Breast conservation surgery
complete local excision and axillary dissection
(usually followed by radiotherapy)
Modified radical mastectomy
total mastectomy and axillary dissection
Classical radical mastectomy
total mastectomy, removal of pectoralis muscles and
axillary dissection
Radiation
Post breast conservation surgery radiotherapy - common indication
Post modified radical mastectomy - for special indications
positive lines of resection
Preoperative radiotherapy for unresectable cancer
Radiotherapy for locoregional recurrences
Palliation for bone metastasis
Systemic
Cytotoxic chemotherapy
Multiagent
Cyclophosphamide, methotrexate, 5-flurouracil
Cyclophosphamide, doxorubicin, 5-fluorouracil
Adjuvant setting (after a locoregional treatment)
Neoadjuvant setting (before a locoregional treatment)
Hormonal manipulations
Hormone receptors
Estrogen receptors
Progesterone receptors
Antiestrogens
Tamoxifen
Ovarian ablation
Oophorectomy
Single modality
Combined modality
Adjuvant
Neoadjuvant
Palliative care
Cancer pain control
Treatment of pleural effusion
Categorization Goal Usual

Treatment
Stage O Early Curative Locoregional
Stage I Early Curative Locoregional
Stage II Early Curative Locoregional

plus adjuvant
Stage III Locally advanced Palliative Locoregional

plus systemic
Stage IV Disseminated Palliative Systemic
10
Practical Mammopathology in Medical Practice

Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg
1999;2000
INTRODUCTION
A complaint in the breast is a very common cause for medical consultation. All physicians should,
therefore, know at least how to evaluate patients with a breast problem. They should know how to manage the cases
that fall within the capability of general practice. They should know when and what cases to refer to breast
specialist.
Complaints on the breast may be any of the following:
1. Pain
2. Lump
3. Nipple discharge
4. Breast enlargement
5. Nipple erosions
The most common complaints are pain and lump.
To investigate a breast complaint, a physician starts off by asking questions about the breast complaint. He
then does a physical examination on the breast, which is the most important part of the investigation.
Examination starts with inspection of the breasts. A physician looks for any gross abnormality that may
suggest or indicate the presence of a pathology. Examples of gross abnormalities are the following:
1. Unilateral gigantic breast

2. Erosions of the nipples
3. Skin retractions
4. Ulcerations
5. Fungating mass
6. Erythema
7. Discharge on the nipple
After inspection comes palpation of the breast. Before palpation, it is a good practice to ask the female
patient if she palpated a lump in her breast before. If she did, she should be asked to point to the area where she
palpated the said lump.
On palpating the breast, the physician should look for a lump which is considered pathologic. S/he looks
for the so-called dominant mass, one that stands out prominently from the rest of the breast tissue. S/he should
try to distinguish a pathologic lump from a lump that is part and parcel of fibrocystic changes. Fibrocystic changes
are physiologic and not pathologic. They usually present as multiple mini-lumps or minute nodulations on the
surface of the breast.
1
Once a pathologic lump is detected, it should be evaluated as to the following:
1. Size
2. Nature of the lump - whether solid or cystic
3. Consistency - whether hard or not hard
4. Tumor border - whether well-defined or ill-defined
5. Presence of tenderness
6. Mobility - whether fixed or mobile
After palpating the breast proper for any lump, the nipple should then be squeezed gently for any discharge.
If there is discharge, its color and character should be noted down, whether serous, milky, or sanguinous.
A complete examination of the breast should include examination of the axillae. These areas should be
palpated for any mass. The mass could be enlarged lymph node or a tumor in the tail of Spence (part of the breast).
MAMMOPATHOLOGY
There are ten breast disorders which all physicians should be familiar with. It is sufficient that they know
when to suspect them after physical examination.
These ten breast disorders are the following:
1. Breast cancer
2. Fibroadenoma
3. Macrocyst
4. Galactocoele
5. Mastitis and breast abscess
6. Intraductal papilloma
7. Benign cystosarcoma phyllodes
8. Tuberculosis of the breast
9. Pagets disease of the nipple
10. Mammomegaly
BREAST CANCER AND PAGETS DISEASE OF THE NIPPLE
Breast cancer should be suspected in a palpable breast lump of any size that is SOLID and that has ILL-
DEFINED BORDERS. This is especially so if any of the following is also present:
1. HARD CONSISTENCY
2. FIXED TO SKIN OR UNDERLYING CHEST WALL
3. SKIN ULCERATION
4. FUNGATING MASS
5. ENLARGED LYMPH NODES IN THE IPSILATERAL AXILLA
2
Pagets disease of the nipple is a special kind of breast cancer. It should be suspected in patients with
NIPPLE OR AREOLAR EROSIONS. A subarealar mass may or may not be present.
Breast cancer usually starts to appear after age 30. Rarely, a younger patient as young as 25 years old or
even younger, may be afflicted with breast cancer.
FIBROADENOMA
Fibroadenoma should be suspected in a palpable breast lump of any size that is FIRM, SOLID,
NONTENDER, VERY MOVABLE, and that has VERY WELL-DEFINED BORDERS. This is especially so if
there are no enlarged lymph nodes in the ipsilateral axilla and if the patient is 25 years old or younger.
MACROCYST
Macrocyst should be suspected in a palpable breast lump of any size that is CYSTIC in nature and that is
seen in a patient with NO HISTORY OF RECENT LACTATION. By cystic nature is meant the wall of the lump
is depressible as to suggest a sac containing fluid.
GALACTOCOELE
Galactocoele should be suspected in a palpable breast lump of any size that is CYSTIC in nature and that is
seen in a patient with a HISTORY OF RECENT LACTATION.
MASTITIS AND BREAST ABSCESS
Mastitis should be suspected in any ERYTHEMATOUS, TENDER, and WARM BREAST WITH NO
PALPABLE LUMP.
Breast abscess should be suspected in a PALPABLE BREAST LUMP of any size that is TENDER,
WARM, and associated with ERYTHEMATOUS overlying skin.
Mastitis and breast abscess are usually encountered in lactating women. They may also be seen in
nonlactating women at any age.
BENIGN CYSTOSARCOMA PHYLLODES
Benign cystosarcoma phyllodes should be suspected in a palpable breast lump that is GIGANTIC, NOT
FIXED TO THE UNDERLYING CHEST WALL, AND THAT IS NOT ASSOCIATED WITH ENLARGED
LYMPH NODES IN THE IPSILATERAL AXILLA. The tumor may be fixed to the overlying skin.
TUBERCULOSIS OF THE BREAST

Tuberculosis should be suspected in a breast with CHRONIC SINUSES. There may or may not be an
underlying lump.
INTRADUCTAL PAPILLOMA
Intraductal papilloma should be suspected when there is BLOODY NIPPLE DISCHARGE WITH NO
PALPABLE BREAST LUMP.
MAMMOMEGALY
Mammomegaly should be suspected of a GIGANTIC BREAST WITH NO UNDERLYING LUMP.

Mammomegaly may be unilateral or bilateral.
DIAGNOSTIC WORK-UP OF A MAMMOPATHOLOGY
The diagnostic tools that may be utilized in a patient with a breast problem consist of the following:
1. Interview
2. Physical examination
3. Diagnostic procedures
4. Monitoring and constant analysis
The initial tools used in investigating a breast problem consist of the interview and physical examination.
After the physical examination, a clinical impression or a diagnosis should be formulated. Depending on the
certainty of the diagnosis formulated, a diagnostic procedure may or may not be instituted. Another option is
monitoring and constant analysis (what is commonly known as observation).
The diagnostic procedures that have been utilized in the work-up of patients with mammopathology consist
of the following:
1. Needle evaluation
2. Open biopsy
3. Mammography
4. Ultrasound
NEEDLE EVALUATION
Needle evaluation uses a hypodermic needle, usually G 19 and 1.5 inch long attached to a 20cc plastic
syringe, to evaluate a lump palpated in the breast. There are three parts in a needle evaluation. One is needling the
lump to check its actual presence; to check its nature, whether solid or cystic; and lastly, to determine its real
consistency, whether gritty or rubbery. Second is aspirating the lump to get samples for gross examination. Third is
preparing a smear out of the samples aspirated for microscopic examination. The third step is what is commonly
known as needle aspiration biopsy.
4
Needle evaluation can be done right after the physical examination in the clinic or office.
The advantages of a needle biopsy are the following:
1. It can give a more definite diagnosis than the physical examination, mammography,
and ultrasound.
2. It is a more cost effective diagnostic procedure than mammography and ultrasound.
3. It can give a more definite diagnosis right after or soon after the physical
examination.
4. It can avoid an operation.
5. It can be therapeutic in galactocoeles and macrocysts.
A real-life situation is given below:
A 45-year-old female presented with a hard nontender breast mass with ill-defined borders. Breast cancer
was suspected. A needle evaluation was done and serous fluid was aspirated and the mass completely disappeared
and did not recur thereafter. The initial impression of breast cancer was changed right away to a definitive diagnosis
of macrocyst.
The macrocyst, although a cyst, did not feel cystic on palpation. It felt hard because it was a tense cyst
filled with fluid.
If a needle evaluation was not done and an operation (open biopsy) was performed, the patient would end
up with an operation which would be considered unnecessary. The needle evaluation performed had avoided the
operation, scar, pain, expenses, and other problems that would accompany the operation if it were instituted.
If a mammography were done, it would just show the shadow of the lump. No definite diagnosis could be
given. The patient would be spending Php 1000.00 and be exposed to radiation.
If an ultrasound were done, it should show a cystic lump. A needle aspiration would still have to be done.
Also, it would take sometime before a definitive diagnosis and treatment could be gotten. With needle evaluation,
the diagnosis and treatment were completed soon after the physical examination.
OPEN BIOPSY
Open biopsy can either be section or excision biopsy. It may be done through a paraffin or a frozen
technique.
Open biopsy is warranted if a needle biopsy is inconclusive.
For all breast masses, it is recommended that a needle evaluation be tried first before considering an open
biopsy. The needle evaluation may be sufficient to establish a definitive diagnosis that an open biopsy is not
necessary anymore.
Another disadvantage of needle evaluation over open biopsy beside avoiding the scar in the latter, is in the
degree of tumor or cancer seeding, if the lump turns out to be cancer. Needle biopsy definitely is associated with
less cancer seeding than open biopsy. Needle biopsy is a biopsy procedure of choice if a patient with breast cancer
wants only a wide excision and not total mastectomy. Chances of local recurrence with a wide excision after an
open biopsy are expected to be higher than those after needle biopsy.
5
MAMMOGRAPHY
Mammography is usually not needed in patients wit a palpable breast mass.
It is used in screening patients with no palpable breast lump for possible cancer. However, with its small
yield, its high cost, the radiation exposure, and the high incidence of false positive and false negative readings,
mammography is not cost-effective and therefore, should not be heavily depended on as a diagnostic screening
procedure. Combined breast self-examination and breast specialist examination is more cost-effective in the
screening of breast cancer.
ULTRASOUND
The needle evaluation has made the use of ultrasound in patients with a breast mass obsolete. The
determination of solid versus cystic in a breast mass by ultrasound can be done using the needle right after the
physical examination and with less cost.
SOME CLINICAL ISSUES IN MAMMOPATHOLOGY
1. All females have a risk of developing breast cancer during their lifetime. The risk is not confined to
females with a family history of breast cancer. So, all females should be on the look-out.
2. The phrase fibrocystic diseases should be discarded. Fibrocystic changes is a better term. For
laymen, a humpy breast is easier to understand and using this terminology can facilitate allayance of fear.
3. Fibrocystic changes do not lead to cancer. Fibrocystic changes are physiologic changes. Operations
done on the breast for fibrocystic changes are unnecessary.
4. Breast pain without a breast lump is mastalgia. This is analogous to the dysmenorrhea in the uterus.
Mastalgia, just like dysmenorrhea, is due to some hormonal mechanism the details of which are not known.
5. Mastalgia is often wrongly associated by laymen with breast cancer. This wrong association and fear of
cancer can aggravate the mastalgia. The approach to patient with mastalgia is first, to tell them they have no lump,
therefore no cancer. Second, to explain the cause of mastalgia (see no.4). Third, to correct the mistaken association
of pain and cancer. Lastly, to give a standby prescription of analgesics. With an adequate advice and explanation,
the analgesics may not be needed at all.
6. The presence of fibroadenoma (established clinically and by needle evaluation) does not constitute an
absolute indication for excision. Operation is indicated when the fibroadenoma is big (at least 3 cm) and, in cases of
smaller fibroadenomas, when patients wish to, despite the proper explanation by the physician. If no operation is
decided upon, monitoring should be done. The rationale for monitoring with option to operate is that more
fibroadenomas can occur in the future and if they do occur, they can be excised in one sitting. This has the
advantage of less scar and less expense.
6
Outline of Clinical Breast Evaluation by the Primary Health Care Physician
Patient
without breast complaint (breast check)
with breast complaint - pain, lump, nipple discharge
|
|
|
Physician
|
|
|
COMPLETE BREAST EXAMINATION
|
|
|
--------------------------------------------------------------
| | |
| | |
Definite Lump Humpy Breast No Lump
| Nodular Breast |
| | |
| | --------------------
| +/- Pain | |
| | | |
| | Pain Discharge
| | | |
| | | |
Cancer Fibrocystic Hormonal Intraductal Papilloma
Fibroadenoma Changes Cause Fibrocystic Changes
Macrocyst | | Cancer
Gatactocoele | | Others
Others | | |
| | | |
| | | |
| -------------------- |
| | |
| | |
| | |
Breast Specialist Advice (allay fear) Breast Specialist
Analgesics
Monitor (Self-Exam)
Check-up
Second opinion
(Breast Specialist)
7
Protocol for Breast Cancer

(1998)
Division of Breast Surgery

Department of Surgery
Philippine General Hospital
I. Diagnosis
A. Basis:
Microscopic evidence of breast cancer - BIOPSY
1. Indications for doing BIOPSY on a breast mass:

a) any breast mass in a woman aged 30 years and above
b) any breast mass in a woman of any age with a family history of breast
cancer in at least one first-degree relative (mother or sister)
c) any breast mass in the contralateral breast of a woman with a history
of breast cancer
d) any hard, ill-defined breast mass in a woman of any age
e) any breast mass fixed to the underlying chest wall, with skin changes
(edema, peau d orange, skin ulceration, satellite skin nodules)
2. Type of BIOPSY
a) Fine needle aspiration biopsy (FNAB) is the initial biopsy procedure for any
palpable breast mass.
b) Core biopsy is done next when FNAB yields non-diagnostic results.
c) Open biopsy
The Division would like to refrain from doing open biopsy and
would recommend it only after a failed core-biopsy procedure.
d) Frozen-section biopsy
The Division would like to refrain from doing frozen-section biopsy
because it is time-consuming and expensive.
B. Staging Manuevers:
1. Individual organ investigation for metastatic work-up should be symptom-directed.
2. Breast mammography for all patients with microscopic evidence of breast cancer.
3. Breast mammography for patients in whom breast conservation surgery is
contemplated.
1
TNM Classification for Breast Cancer (AJCC/UICC 1993)
Primary Tumor (T)

TX Primary tumor cannot be assessed
T0 No evidence of a primary tumor
Tis Carcinoma in situ: DCIS, LCIS, or Pagets disease of the nipple with no mass
T1 Tumor 2 cm or less in greatest dimension
T1a 0.5 cm or less in dimension
T1b More than 0.5 cm but not more than 1 cm in greatest dimension
T1c More than 1 cm but not more than 2 cm in greatest dimension
T2 Tumor more than 2 cm but not more than 5 cm in greatest dimension
T3 Tumor more than 5 cm in greatest dimension
T4 Tumor of any size with direct extension to chest wall or skin
T4a Extension to chest wall
T4b Edema (including peau dorange) or ulceration of the skin of the
breast or satellite skin nodules confined to the same breast
T4c Both T4a and T4b
T4d Inflammatory carcinoma: A clinicopathologic entity characterized by diffuse
brawny induration of the skin of the breast with an erysipeloid edge, usually
without an underlying mass. Radiologically, there may be a detectable mass
and the characteristic thickening of the skin over the breast. This clinical
presentation is due to tumor embolization of dermal lymphatics.
Note: Pagets disease associated with a tumor is classified according to the size of the tumor.
Regional Lymph Nodes (N)
NX Regional lymph nodes cannot be assessed (eg. previously removed)

N0 No regional lymph node metastasis
N1 Metastasis to ipsilateral axillary lymph nodes, movable
N2 Metastasis to ipsilateral axillary lymph nodes, fixed to one another or to other structures
N3 Metastasis to ipsilateral internal mammary lymph nodes
Distant Metastasis (M)
MX Presence of distant metastasis cannot be assessed

M0 No distant metastasis
M1 Distant metastasis (includes metastasis to ipsilateral supraclavicular lymph nodes)
2
Stage Grouping
Stage 0 Tis N0 M0
Stage I T1 N0 M0
Stage IIA T2 N0 M0
T1 N1 M0
T0 N1 M0
Stage IIB T3 N0 M0
T2 N1 M0
Stage IIIA T3 N1 M0
T3 N2 M0
T2 N2 M0
T1 N2 M0
T0 N2 M0
Stage IIIB T4 Any N M0

Any T N3 M0
Stage IV Any T Any N M1

3
II. TREATMENT
A. Goals of Treatment
1. CURE - for Stage I to Stage IIIA
2. PALLIATION - for Stage IIIB and Stage IV
a. Locoregional control of the disease is the goal in Stage IIIB
b. Palliation of symptoms, primarily pain and dyspnea due to pleural effusion,
are the goals for Stage IV patients
B. Treatment Plans: based on pathologic staging (pTNM)

1. Stage I - II
a) Definitive treatment: Modified radical mastectomy (MRM)
or breast conservation surgery + radiotherapy
Contraindications for breast conservation + radiotherapy:

1. Patients refusal of procedure
2. Small-sized breast
3. Inaccessibility or unavailability of radiotherapy
4. Multicentricity of tumor
b) Adjuvant treatment:
N0 No adjuvant treatment
N(+)
Premenopausal
ER(+) Chemotherapy*
Surgical oophorectomy is an alternative
ER(-) Chemotherapy
ER unknown Chemotherapy
Postmenopausal
ER(+) Tamoxifen**
ER(-) Tamoxifen or chemotherapy
ER unknown Tamoxifen
*Chemotherapy Regimen (CMF regimen, 21 day cycle, 6 courses)
Cyclophosphamide 500 mg/m2 given IV

Methotrexate 40 mg/m2 given IV
5-Fluoro-uracil 600mg/m2 given IV
** Tamoxifen is given 20 mg daily for 2 to 5 years, preferably 5 years.
2. Stage IIIA
a) Definitive Treatment: MRM
b) Adjuvant Treatment: same guidelines as in node-positive Stage II patients
3. Stage IIIB (Locally advanced breast cancer)

The objective of treatment for Stage IIIB is locoregional control of the disease.
Current evidence shows improved results of treatment with a multimodality
approach. However, at present, there is not evidence to recommend a standard
treatment protocol. Based on available data, the Divisions recommendation is
to individualize treatment adopting a multimodal (surgery, chemotherapy,
hormonal therapy, and radiotherapy) regimen that is judged to be best for the
particular patient.
4. Stage IV
The goal of treatment is to palliate symptoms.
1. Pain Control
a) Analgesics - following the guideline of the World Health
Organization
(Stepladder approach starting with paracetamol and NSAIDs
and shifting to oral morphine for pain unrelieved by the first-
line drugs)
2. Site-specific measures to palliate symptoms brought about by specific sites of

metastasis
a) Bone and soft tissue metastasis
i for focal or localized involvement - analgesics + RT
ii for diffuse disease - analgesics + tamoxifen for
ER(+) patients
- analgesics +chemotherapy for
ER(-) patients
b) Visceral metastasis - analgesics
i for pleural effusion - initial thoracentesis
- tube thoracostomy with pleurodesis
for first recurrence
c) CNS metastasis - analgesics + RT
3. Surgery and/or radiotherapy could be done for the primary in the breast
and/or chest wall recurrence for local control, ONLY if significant
palliation can be achieved.
III. Protocol for Surgical Management
A. Preoperative
1. History and physical examination directed evaluation of surgical risk
2. No prophylactic antibiotics unless
a) patient is ASA II-III
b) estimated duration of operation is beyond 4 hours
3. Tetanus prophylaxis and therapeutic antibiotics for ulcerated tumors
4. Rehabilitation medicine consult for all patients for MRM and axillary dissection
5
B. Intraoperative
1. Decision to perform a procedure more extensive than MRM, i.e. removal of the
pectoralis muscles is as indicated
2. Routine use of suction drain for axillary dissection
C. Post-operative
1. Routine use of any combination of analgesics resulting in a pain-free post-operative
period
2. Arm rehabilitation exercises
3. Discharge within 48 hours post-operation with tube drain and with instructions on
a) care of tube drain
b) intake of analgesics
c) arm rehabilitation exercises
d) first follow-up within 5-7 days of discharge
D. Follow-up
1. Second follow-up is 30 days after the operation.
2. Adjuvant treatment is started within 6 weeks of the operation.
3. Frequency of follow-up:
a) First 2 years - every 6 months
- patients are given instructions to consult earlier if with
symptoms
b) After 2 years - yearly
4. Annual contralateral mammogram for mastectomized patients.
5. Annual mammogram for patients who underwent breast conservation surgery.
6. Symptom-directed metastatic work-up
7. Annual gynecologic evaluation is advised for patients on tamoxifen.
6
THE BREAST
HEALTH PROBLEM
BREAST DISORDER
FOLDER 6
EVALUATION
Note: Two sets of Pretest

Pretest I - 25 items - for classroom use
Pretest II - 200 items - for independent study
Written Examination
Instructions:
1. Use BLACK or BLUE ballpoint for your final answers.
2. Place your answers on the answer sheets provided.

Shade the appropriate circle under each number.
There must only be ONE shaded circle as your answer.
3. For those questions with lettered options (A, B, C, D, E),

choose ONE best answer.
4. For those questions with numbered options (1, 2, 3, 4),

answer as follows:
A - if only nos. 1, 2, and 3 options are correct

B - if only nos. 1 and 3 options are correct
C - if only nos. 2 and 4 options are correct
D - if only no. 4 option is correct
E - if all options are correct
5. For matching-type questions,

an option may be used MORE THAN ONCE.
Student ID: ________________________________ Score: __________________
Subject: Breast Disorders (Pretest I)
A B C D E
1. O O O O O
2. O O O O O
3. O O O O O
4. O O O O O
5. O O O O O
A B C D E
6. O O O O O
7. O O O O O
8. O O O O O
9. O O O O O
10. O O O O O
A B C D E
11. O O O O O
12. O O O O O
13. O O O O O
14. O O O O O
15. O O O O O
A B C D E
16. O O O O O
17. O O O O O
18. O O O O O
19. O O O O O
20. O O O O O
A B C D E
21. O O O O O
22. O O O O O
23. O O O O O
24. O O O O O
25. O O O O O
BREAST HEALTH PROBLEM - BREAST DISORDERS
Pretest I
Anatomy
1. Which of the following statements on the anatomy of the breast is/are valid?
1. It consists of 15 -20 lobes of glandular tissues of the tubuloalveolar type

2. Involvement of the cooper ligament explains the skin retraction in breast cancer
3. The axillary tail of Spence accounts for the relatively biggest area in the upper outer
quadrant of the breast
4. The boundaries of the breast consist of 2nd to 3rd to 6th to 7th rib, anterior or
mid-axillary line, and parasternal line.
1. The breast is a modified sweat gland

2. The Montgomery tubercles are sebaceous glands seen on the areola
3. There are smooth muscles in the nipple-areolar complex that account for erection of
the nipple
4. The breast proper is made up of a ductal-areolar system surrounded by fatty tissues
Physiology
3. In women, estrogens have all the following effects EXCEPT they
A. facilitate the growth of ovarian follicles

B. cause cyclic changes in the vagina and endometrium
C. cause cervical mucus to become thinner and more alkaline
D. produce ductal proliferation in the breast
E. produce glandular proliferation in the breast
4. Correct statements regarding lactation following delivery include that
1. menstruation may resume by 6 to 8 weeks in most nonlactating women

2. approximately one-third of lactating women will resume menses by 3 months
3. ovulation may occur within 6 weeks in lactating women
4. women treated with bromocriptine for lactation suppression may ovulate by the second
postpartum week
5. In the mother, suckling leads to which of the following responses?
1. Release of oxytocin
2. Decrease of prolactin inhibition
3. Decrease of hypothalamic dopamine
4. Increase of luteinizing-hormone releasing factor
Epidemiology
6. Regarding the epidemiology of breast cancer in the Philippines, at present
1. it is the second most common overall cancer (among males and females)
2. it is the most common cancer among females
3. the incidence in Filipino females starts to rise after age 30
4. female breast cancers are more common than male breast cancers with a ratio of 100:1
7. The reasons why breast cancer is a public health problem in the Philippines consist of:
1. it is a very common cancer in the country

2. the fatality rate is high
3. the specific cause is not known making prevention and treatment difficult
4. there is a lack of coordinated effort in the breast cancer control program
8. Regarding a breast cancer control program in a community,
1. its present goals should be to reduce sufferings and death from the disease
2. to be successful, it must utilize a primary health care approach emphasizing on people
empowerment and multisectoral cooperation
3. at present, its strategy should focus on early detection and treatment
4. its realistic aim is to eradicate the disease
Etiology and risk factors
9. Regarding etiology and risk factors of breast cancer in females and their clinical application,
1. the exact etiology is not known
2. age is a more important risk factor than family history of breast cancer because majority of
breast cancer patients have negative family history
3. to date, knowledge about the risk factors has NOT translated into practical ways to prevent
breast cancer
4. to date, early detection and treatment is the most practical way to reduce the magnitude of the
breast cancer problem
10. Regarding the etiology and risk factors of breast cancer in females, at present , the following are strongly
considered:
1. inheritance of an altered tumor suppressor gene such a p53 and BRCA1 and BRCA2
2. acquired mutation of breast cancer suppressor gene secondary to hormonal-environmental
factors
3. prolonged uninterrupted exposure of the breast to the effect of hormones such as estrogens and
progesterones
4. obesity in both premenopausal and postmenopausal women
Early detection of breast cancer
11. Regarding programs on early detection of breast cancer,
1. strategies include screening for people at moderate to high risk of developing breast cancer,
early consultation for any breast symptoms, public health education, and health
professionals education
2. annual mammography is widely accepted as a screening for early breast cancer in females
aged 50 and above and those with a history of treated breast cancer.
3. monthly breast self-examination and annual clinical breast examination are widely accepted as
minimum screening procedures for people at risk of developing breast cancer.
4. genetic testing for breast cancer susceptibility genes such as BRCA1 and BRCA2 is an
accepted screening procedure for early detection of breast cancer.
Pathology
12. Regarding pathology of the breast ,
1. majority of breast masses are nonmalignant

2. majority of nonmalignant solid breast masses are fibroadenoma
3. majority of malignant breast masses are infiltrating ductal carcinoma
4. majority of malignant lesions discovered by mammography are lobular carcinoma in situ
Clinical diagnosis
13. A 29-year-old female patient presents with a very movable non-tender solid breast mass with well-defined
border. There is no palpable axillary lymph node. The primary clinical diagnosis is:
A. breast abscess
B. breast cancer
C. fibroadenoma
D. fibrocystic changes
E. phyllodes tumor
14. A female patient presents with mastalgia and nodular breast tissues with NO dominant mass. There is NO
axillary node. The primary clinical diagnosis is:
A. breast abscess
B. breast cancer
C. fibroadenoma
E. mastitis
15. A female patient presents with a hard breast mass with ill-defined border, fixed, with a palpable ipsilateral
axillary lymph node. The primary clinical diagnosis is:
A. breast abscess
B. breast cancer
C. fibroadenoma
E. tuberculosis of the breast
16. A female patient presents with a tender breast mass with erythema over the skin. The primary clinical diagnosis
is:
A. breast abscess
B. breast cancer
C. fibroadenoma
17. In any patient with a palpable breast mass in which the physician is not certain and wants to be more definite
about the clinical diagnosis, the most cost-effective paraclinical or ancillary diagnostic procedure is:
A. mammography
B. ultrasound
C. CT scan
D. biopsy
E. MRI
18. Regarding staging of breast cancer,
1. it can be used as a guide in treatment

2. it consists of five stages in the widely accepted TNM staging system (Stage 0 to IV)
3. it can be used in prognostication
4. stage II is still considered early breast cancer
Treatment
19. The primary treatment for early breast cancer is:
A. surgery of the breast

B. radiotherapy
C. cytotoxic chemotherapy
D. hormonal manipulation - tamoxifen
E. hormonal manipulation -oophorectomy
20. Consider the statements on treatment of breast cancer.
1. early breast cancers are usually treated by locoregional modalities like surgery and
radiotherapy while late and disseminated cancers are usually treated by systemic
modalities like cytotoxic chemotherapy and hormonal manipulation.
2. the goal of treatment for early breast cancer is cure while that for late and disseminated ones,
palliation
3. There is no difference in the rate of survival or distant metastasis between women having total
mastectomy and those having breast conservation surgery where appropriate.
4. Modified radical mastectomy achieves results similar to those achieved by the classical
radical mastectomy.
Systemic adjuvant therapy
21. The aims of systemic adjuvant therapy after local therapy of early breast cancer are to:
1. treat undetectable cancer

2. reduce risk of clinically evident metastatic disease
3. reduce risk of local recurrence
4. improve survival
22. The most reliable indicator for a systemic adjuvant therapy after local therapy of early breast cancer is:
A. positive evidence of axillary lymph node metastasis

B. big tumor size
C. negative hormonal receptor
D. high histologic grade
E. distant metastasis
23. In premenopausal women with breast cancer needing systemic adjuvant therapy after surgery, the usual
recommendation is:
A. cytotoxic chemotherapy
B. tamoxifen
C. surgical oophorectomy
D. radiation oophorectomy
E. medical oophorectomy
24. In postmenopausal women with breast cancer needing systemic adjuvant therapy after surgery, the usual
recommendation is:
B. tamoxifen
Follow-up and prognosis
25. Regarding follow-up and prognosis,
1. the aims of followup consist of cost-effective way of early detection of recurrence, screening
for a new primary breast cancer in early breast cancer, detection of treatment related
toxicities, and provision of psychosocial support
2. the followup should be life-time
3. for detection of distant metastasis, diagnostic procedures should be symptom-directed because
evidences have shown no difference in survival between intensive versus minimalist
followup program
4. ultimately the single most important determinant of prognosis is the biologic behavior of the
cancer in a particular individual
Pretest I
Anatomy
E
E
the nipple
Physiology

E

E
postpartum week

A
Epidemiology

E
E
A
Etiology and risk factors
E
breast cancer
considered:
A
factors
progesterones
Early detection of breast cancer

A
Pathology
A
Clinical diagnosis
C
A. breast abscess
B. breast cancer
C. fibroadenoma
E. phyllodes tumor
D
A. breast abscess
B. breast cancer
C. fibroadenoma
E. mastitis
B
A. breast abscess
B. breast cancer
C. fibroadenoma
16. A female patient presents with a tender breast mass with erythema over the skin. The primary clinical diagnosis
is:
A
A. breast abscess
B. breast cancer
C. fibroadenoma
D
A. mammography
B. ultrasound
C. CT scan
D. biopsy
E. MRI

E
Treatment

A
B. radiotherapy

E
palliation
radical mastectomy.
Systemic adjuvant therapy
E
4. improve survival
A
B. big tumor size
recommendation is:
A
B. tamoxifen
recommendation is:
B
B. tamoxifen
Follow-up and prognosis
25. Regarding follow-up and prognosis,

E
followup program
Content Blueprint for Comprehensive Exam
Content
The normal breast
Breast disorders
Biomedical-Issues
Biomedical
Pathophysiology
Anatomy
Physiology
Pathology
Microbiology
Epidemiology
Diagnosis
Treatment
Pharmacology - therapeutics
Cytotoxic chemotherapy
Antibiotics
Surgery
Radiotherapy
Issues
Preventive Medicine and Public Health
Psychosocial - psychiatry
Public Health
Research
Legal Medicine, Medical Jurisprudence, Bioethics
Blueprint for Pretest
Biomedical-Issues
Pretest
200 Items
Biomedical 190
Pathophysiology 98
Anatomy 17
Physiology 28
Pathology 51
Microbiology 2
Diagnosis 56
Treatment 36
Issues 10
Written Examination
Instructions:
1. Use BLACK or BLUE ballpoint for your final answers.
2. Place your answers on the answer sheets provided.

Shade the appropriate circle under each number.
There must only be ONE shaded circle as your answer.
3. For those questions with lettered options (A, B, C, D, E),

choose ONE best answer.
4. For those questions with numbered options (1, 2, 3, 4),

answer as follows:
A - if only nos. 1, 2, and 3 options are correct

B - if only nos. 1 and 3 options are correct
C - if only nos. 2 and 4 options are correct
D - if only no. 4 option is correct
E - if all options are correct
5. For matching-type questions,

an option may be used MORE THAN ONCE.
Student ID: ________________________________ Score: __________________
Subject: Breast Disorders (Pretest)

A B C D E A B C D E
1. O O O O O 26. O O O O O
2. O O O O O 27. O O O O O
3. O O O O O 28. O O O O O
4. O O O O O 29. O O O O O
5. O O O O O 30. O O O O O
A B C D E A B C D E
6. O O O O O 31. O O O O O
7. O O O O O 32. O O O O O
8. O O O O O 33. O O O O O
9. O O O O O 34. O O O O O
10. O O O O O 35. O O O O O
A B C D E A B C D E
11. O O O O O 36. O O O O O
12. O O O O O 37. O O O O O
13. O O O O O 38. O O O O O
14. O O O O O 39. O O O O O
15. O O O O O 40. O O O O O
A B C D E A B C D E
16. O O O O O 41. O O O O O
17. O O O O O 42. O O O O O
18. O O O O O 43. O O O O O
19. O O O O O 44. O O O O O
20. O O O O O 45. O O O O O
A B C D E A B C D E
21. O O O O O 46. O O O O O
22. O O O O O 47. O O O O O
23. O O O O O 48. O O O O O
24. O O O O O 49. O O O O O
25. O O O O O 50. O O O O O
Student ID: ________________________________ Score: __________________

A B C D E A B C D E
51. O O O O O 76. O O O O O
52. O O O O O 77. O O O O O
53. O O O O O 78. O O O O O
54. O O O O O 79. O O O O O
55. O O O O O 80. O O O O O
A B C D E A B C D E
56. O O O O O 81. O O O O O
57. O O O O O 82. O O O O O
58. O O O O O 83. O O O O O
59. O O O O O 84. O O O O O
60. O O O O O 85. O O O O O
A B C D E A B C D E
61. O O O O O 86. O O O O O
62. O O O O O 87. O O O O O
63. O O O O O 88. O O O O O
64. O O O O O 89. O O O O O
65. O O O O O 90. O O O O O
A B C D E A B C D E
66. O O O O O 91. O O O O O
67. O O O O O 92. O O O O O
68. O O O O O 93. O O O O O
69. O O O O O 94. O O O O O
70. O O O O O 95. O O O O O
A B C D E A B C D E
71. O O O O O 96. O O O O O
72. O O O O O 97. O O O O O
73. O O O O O 98. O O O O O
74. O O O O O 99. O O O O O
75. O O O O O 100. O O O O O
Student ID: ________________________________ Score: __________________

A B C D E A B C D E
101. O O O O O 126. O O O O O
102. O O O O O 127. O O O O O
103. O O O O O 128. O O O O O
104. O O O O O 129. O O O O O
105. O O O O O 130. O O O O O
A B C D E A B C D E
106. O O O O O 131. O O O O O
107. O O O O O 132. O O O O O
108. O O O O O 133. O O O O O
109. O O O O O 134. O O O O O
110. O O O O O 135. O O O O O
A B C D E A B C D E
111. O O O O O 136. O O O O O
112. O O O O O 137. O O O O O
113. O O O O O 138. O O O O O
114. O O O O O 139. O O O O O
115. O O O O O 140. O O O O O
A B C D E A B C D E
116. O O O O O 141. O O O O O
117. O O O O O 142. O O O O O
118. O O O O O 143. O O O O O
119. O O O O O 144. O O O O O
120. O O O O O 145. O O O O O
A B C D E A B C D E
121. O O O O O 146. O O O O O
122. O O O O O 147. O O O O O
123. O O O O O 148. O O O O O
124. O O O O O 149. O O O O O
125. O O O O O 150. O O O O O
Student ID: ________________________________ Score: __________________

A B C D E A B C D E
151. O O O O O 176. O O O O O
152. O O O O O 177. O O O O O
153. O O O O O 178. O O O O O
154. O O O O O 179. O O O O O
155. O O O O O 180. O O O O O
A B C D E A B C D E
156. O O O O O 181. O O O O O
157. O O O O O 182. O O O O O
158. O O O O O 183. O O O O O
159. O O O O O 184. O O O O O
160. O O O O O 185. O O O O O
A B C D E A B C D E
161. O O O O O 186. O O O O O
162. O O O O O 187. O O O O O
163. O O O O O 188. O O O O O
164. O O O O O 189. O O O O O
165. O O O O O 190. O O O O O
A B C D E A B C D E
166. O O O O O 191. O O O O O
167. O O O O O 192. O O O O O
168. O O O O O 193. O O O O O
169. O O O O O 194. O O O O O
170. O O O O O 195. O O O O O
A B C D E A B C D E
171. O O O O O 196. O O O O O
172. O O O O O 197. O O O O O
173. O O O O O 198. O O O O O
174. O O O O O 199. O O O O O
175. O O O O O 200. O O O O O
Breast Disorders
Pretest Items
BIOMEDICAL
Pathophysiology (Anatomy, Physiology, Pathology, Microbiology)
ANATOMY (#1-17= 17)
1. Which of the following statements about milk lines is FALSE?

C
A. they are common to all mammals
B. between 2% to 6% of human females have an accessory nipple or extramammary breast tissue
C. milk lines are derived from endoderm
D. they extend from the axilla to the inguinal region
E. none of the above
2. Which one of the following tissues is the most significant component of the female breast, giving it size and
characteristic shape?
D
A. glandular tissue
B. ductal tissue
C. fibrous tissue
D. fatty tissue
3. Which one of the following breast quadrants has the highest incidence of breast cancers being diagnosed?
A
A. upper outer
B. lower outer
C. upper inner
D. lower inner
E
E
the nipple
Questions 6-9
Match the characteristics of the axillary nodes with their corresponding levels as seen in breast cancer surgery.
A. Level I
B. Level II
C. Level III
D. Level IV
E. None of the above
6. Nodes immediately behind the pectoralis minor muscle

B
7. Nodes below the level of the pectoralis minor muscle
A
8. Presence of nodes at this level is an indicator of a more advanced disease
C
9. Nodes between the pectoralis major and minor muscles
E
Questions 10 - 14
Match the congenital events in the breast with their corresponding terminologies.
A. Milk line
B. Polymastia
C. Polythelia
D. Hypomastia
E. Macromastia
10. Areas where accessory breast/nipple may occur extending from axilla to the inguinal area
A
11. With accessory breasts
B
12. With accessory nipple
C
13. Underdeveloped breasts
D
14. Overdeveloped breasts
E
Questions 15-17
Match the characteristics of the breast with the stage in breast development.
A. Adolescent breast
B. Pregnant breast
C. Lactating breast
D. Postmenopausal breast
15. Smallest in size

A
16. Largest in size
C
17. Involution of ductal and glandular components
D
PHYSIOLOGY (#18- 45= 28)
18. The primary hormone responsible for lactogenesis is

C
A. oxytocin
B. estrogen
C. prolactin
D. luteinizing hormone (LH)
E. follicle-stimulating hormone (FSH)
19. Which one of the following statements about prolactin is correct?

D
A. It initiates ovulation
B. It causes milk ejection during suckling
C. It inhibits the growth of breast tissue
D. Its secretion is tonically inhibited by the hypothalamus
E. Its secretion is increased by dopamine
E
21. Contraindications to breast feeding include all the following EXCEPT

C
A. maternal hepatitis B
B. maternal reduction mammoplasty with transplantation of the nipples
C. maternal acute puerperal mastitis
D. maternal treatment with lithium carbonate
E. maternal treatment with tetracyclines
22. Puerperal fever from breast engorgement

D
1. appears 3 to 4 days after the development of lacteal secretion
2. is almost painless
3. rarely exceeds 37.5 C
4. is less severe and less common if lactation is suppressed

E
postpartum week

A
25. All of the following statements concerning response of the breast to the hormonal changes associated with
pregnancy are true EXCEPT
B
A. ducts and lobules proliferate under the influence of increased estrogen and progesterone
B. increased oxytocin levels induce the synthesis of milk fats during the last trimester
C. the alveoli are filled with colloid during the second trimester
D. connective and adipose tissue is replaced by proliferating glandular epithelium
E. the alveoli are filled with colostrum in the third trimester
26. Which one of the following statements regarding breast development is correct?
D
A. Completion of breast unit development occurs at puberty
B. Breast precursors arise from mesodermal origin
C. Proliferation of breast components at puberty is called pubarche
D. Multiple pairs of breast buds are present in embryonic life
27. Which one of the following is the most significant constituent of human breast milk by weight?
B
A. carbohydrate
B. water
C. protein
D. lipid
E. enzymes
28. Which one of the following is the predominant immunoglobin (Ig) in human breast milk?
C
A. Immunoglobulin M (IgM)
B. IgE
C. IgA
D. IgG
E. IgF
Questions 29-31
For each of the following characteristics, select the appropriate physiologic breast function.
A. Mammogenesis
B. Lactogenesis
C. Galactopoiesis
D. None of the above
29. Maintain by emptying the alveoli

C
30. Requires rapidly declining levels of multiple hormones
B
31. Requires high level of multiple hormones
A
Questions 32-35
For each hormone that follows, select its appropriate function in breast development and lactation.
A. Plays a background role in breast development

B. Stimulates development of alveolar components
C. Stimulates growth of ductal system
D. Stimulates milk let-down
32. Progesterone
B
33. Estradiol
C
34. Oxytocin
D
35. Insulin
A
Questions 36-38
Match the types of breast secretion with their corresponding terminologies.
A. Witchs milk
B. Colostrum
C. Galactorrhea
D. Hemotorrhea
36. Breast secretion in the newborn male or female

A
37. Breast secretion in the first few days after postpartum
B
38. Milky secretion from the breast even after weaning
C
Questions 39-41
Match the hormones responsible for the breast events.
A. Estrogen
B. Progesterone
C. Prolactin
D. Oxytocin
39. Ductal development

A
40. Lobular or alveolar development
B
41. Lactogenesis
C
Questions 42-45
Match the descriptions of usual and unusual breast enlargement with their corresponding terminologies.
A. Gynecomastia
B. Macromastia
C. Virginal hypertrophy
D. Discoid hypertrophy
42. Presence of female-type mammary gland in male

A
43. Markedly enlarged breast, referring usually to the female breast, not due to tumor or pregnancy
B
44. Markedly enlarged breast, usually in young females, not due to tumor or pregnancy
C
45. Represents early stage of breast development
D
PATHOLOGY (#46 - 96 = 51)
46. A 37-year-old woman presents with a lump in the upper outer quadrant of the left breast, which shows a wide
spectrum of benign breast disease on pathologic examination. Which of the following is considered to indicate the
greatest risk for subsequent carcinoma of the breast?
E
A. Intraductal papillomatosis
B. Sclerosing adenosis
C. Focal papillomatosis
D. Marked apocrine metaplasia
E. Epithelial hyperplasia of the ducts
47. A 23-year-old woman presents with a rubbery, freely movable 2-cm mass in the upper outer quadrant of the left
breast. A biopsy of this lesion would most likely histologically reveal
E
A. large number of neutrophils
B. large number of plasma cells
C. duct ectasia with inspissation of breast secretions
D. necrotic fat surrounded by lipid-laden macrophages
E. a mixture of fibrous tissue and ducts
48. A papillary lesion is seen in a biopsy from a 32-year-old woman who presented with sanguineous discharge from
the nipple. All the following would be useful in differentiating benign intraductal papilloma from papillary
adenocarcinoma EXCEPT
D
A. a cribriform pattern
B. knowledge of the presence or absence of cell uniformity
C. fibrovascular cores
D. the age of the patient
E. two cell types (epithelial and myoepithelial)
49. A menopausal woman is given a diagnosis of lobular carcinoma of the breast. True statements regarding this
lesion include all the following EXCEPT
B
A. it represents about 10 percent of breast carcinomas
B. epidermal infiltration is characteristic
C. biopsies of the contralateral breast are indicated
D. it tends to be multifocal
E. a single file pattern of infiltration is characteristic
50. Clinical risk factors for development of carcinoma of the female breast include all the following EXCEPT
A
A. early menopause
B. nulliparity
C. history of endometrial cancer
D. early menarche
E. obesity
51. Which of the following statements most accurately describes inflammatory breast cancer?
E
A. Inflammation improves the prognosis
B. Inflammation is increased in Pagets disease
C. Acute inflammatory cells are present
D. Chronic inflammatory cells are present
E. Lymphatic permeation is present
52. The most important factor related to the prognosis of breast carcinoma is the
D
A. presence of activated oncogenes
B. histologic type and grade
C. size of the tumor
D. status of axillary lymph nodes
E. presence of estrogen receptors
53. An excisional biopsy of the nipple area, taken from a 46-year-old woman, shows infiltration of the nipple by
large cells with clear cytoplasm. The patient complained of discharge from the nipple for approximately 4 months.
The most likely diagnosis is
D
A. fibroadenoma
B. epidermoid carcinoma
C. eczematous inflammation
D. Pagets disease of the breast
E. mammary fibromatosis
54. A number of malignant tumors of the breast have been known in some instances to have a deceptively bland
histologic appearance and hence have at times been misdiagnosed as benign by the pathologist. These potentially
deceptive tumors include all the following EXCEPT
A
A. duct carcinoma
B. tubular carcinoma
C. angiosarcoma
D. papillary sarcoma
E. metastasizing mucinous carcinoma
55. All the following factors have shown an association with gynecomastia EXCEPT
B
A. Leydig cell tumors
B. seminomas
C. Sertoli cell tumors
D. alcoholic cirrhosis
E. digitalis therapy
56. Gynecomastia is associated with which of the following conditions?
E
A. diazepam usage
B. puberty
C. aging
D. cirrhosis
E. all of the above
57. Regarding gynecomastia, assess the validity of the following statements:

E
1. It is more often physiologic than pathologic.
2. The pathophysiologic mechanism is mainly due to estrogen excess or relative hyperestrinism.
3. It must be differentiated from breast cancer in males 40 years and above.
4. For large gynecomastia refractory to conservative management, transareolar mastectomy
is the procedure of choice.
58. The following conditions may initiate gynecomastia:

E
1. Renal failure causing androgen deficiency state
2. Drugs that inhibit testosterone-related activity
3. Primary and secondary testicular failure
4. Germ cell tumors
Questions 59-66
Match the types of gynecomastia with the causes.
A. Physiologic neonatal gynecomastia

B. Physiologic adolescent gynecomastia
C. Physiologic senescent gynecomastia
D. Pathologic gynecomastia
E. Breast cancer in the male
59. Due to placental estrogens

A
60. Due to excess of estradiol relative to testosterone during development
B
61. Due to decreased plasma testosterone and increased plasma testosterone-binding globulin as part of development
C
62. 2-cm retroarealor breast tissue in an elderly male with no evident systemic disease nor drug intake
C
63. 2-cm lump more to one side of the nipple in an elderly male
E
64. Klinefelter syndrome (47, XXY)
D
65. Renal failure
D
66. Drug-related conditions
D
Questions 67-69
A. Is characteristically painful
B. May have mesenchymal differentiation
C. Is frequently bilateral
D. Never predisposes to carcinoma
E. Produces scirrhous tumors
67. Ductal carcinoma

E
68. Sclerosing adenosis
D
69. Cystosarcoma phyllodes
B
70. All of the following are associated with an increased risk of breast cancer EXCEPT
D
A. dietary consumption of fat
B. history of breast cancer in first-degree maternal relatives
C. age over 35
D. early first pregnancy
E. infertility
71. The MOST frequent histologic type of breast carcinoma is

B
A. infiltrating papillary carcinoma
B. infiltrating ductal carcinoma
C. infiltrating lobular carcinoma
D. colloid carcinoma
E. medullary carcinoma
72. All of the following statements concerning nipple discharges are true EXCEPT
B
A. they may be caused by multiple lesions
B. when bloody, the discharge is due to a malignancy 70% of the time
C. a milky discharge may be due to a pituitary adenoma
D. benign duct papillomas are the most common cause of bloody discharges
E. excision of the involved duct may be necessary to determine the etiology
73. The MOST frequent site for breast cancer to develop is the
D
A. upper inner quadrant
B. lower inner quadrant
C. lower outer quadrant
D. upper outer quadrant
E. subareolar zone
74. The risk of bilateral breast cancer is HIGHEST if the first breast shows
B
A. inflammatory carcinoma
B. lobular carcinoma
C. medullary carcinoma
D. infiltrating ductal carcinoma
E. Pagets disease
75. All of the following are true statements concerning Pagets disease of the nipple EXCEPT
B
A. it is very uncommon, accounting for only 2% of all breast cancers
B. it is an in situ squamous cell malignancy of the nipple
C. it is an eczematoid lesion
D. it has a better prognosis than the majority of other breast cancers
E. it can be confused with malignant melanoma histologically
76. Which of the following statements concerning carcinoma of the breast are true?
E
1. The most common type is the infiltrating ductal carcinoma
2. Lobular carcinoma in situ is frequently bilateral
3. Its incidence is increased in women with atypical epithelial hyperplasia
4. Medullary carcinoma has a poor prognosis
77. Bilateral primary cancer of the breast is most likely to develop in association with which of the following
tumors?
B
A. medullary carcinoma
B. lobular carcinoma
C. colloid carcinoma
D. ductal carcinoma
E. cystosarcoma phyllodes
78. All the following statements concerning fat necrosis of the breast are true EXCEPT that
C
A. it usually is associated with a history of trauma
B. it usually occurs in large, pendulous breast
C. it predisposes patient to the development of breast cancer
D. liquefaction of fat may produce cystic spaces
E. the treatment of choice is local excision
79. Correct statements concerning cystosarcoma phyllodes include which of the following?
B
1. The age of peak incidence is somewhat less than in epithelial breast carcinoma
2. The lesion is a true sarcoma, is invasive, and is characterized by axillary metastasis
3. Although the tumor may become quite large, dermal involvement usually does not occur
4. Modified radical mastectomy is usually the treatment of choice
80. An obese 40-year-old woman presents with a mass in her left breast. The lesion is very firm and exhibits skin
retraction. Which of the following disorders or precipitating factors should be considered in the pathogenesis of this
lesion?
E
1. rupture of a duct in fibrocystic changes
2. severe breast trauma
3. previous breast biopsy
4. infiltrating duct carcinoma
81. Which one of the following conditions is a risk factor for breast cancer?
C
A. multiparity
B. late menarche
C. delayed childbearing
D. high carbohydrate diet
E. fibroadenoma
82. Pagets disease is characterized by all the following statements EXCEPT

D
A. it occurs in the nipple and vulva
B. local recurrences are common
C. it is often associated with subadjacent adenocarcinoma or squamous cell carcinoma
D. cells often stain darker than the surrounding keratinocytes
E. surgery is the best treatment
83. Of the following, the most significant risk factor for developing breast cancer is
C
A. the presence of sclerosing adenosis
B. nulliparity
C. atypical lobular hyperplasia
D. atypical ductal hyperplasia
E. menarche before age 12
84. Which of the following statements about breast cancer is TRUE?

C
A. It is the most common cause of a bloody nipple discharge
B. A bloody nipple discharge is usually the initial symptom
C. Well over 50% of malignant tumors are infiltrating duct carcinomas
D. Most breast masses are initially found by the physician
E. It is often preceded by breast cysts
85. The risk of breast cancer is increased by

C
1. teenage pregnancy
2. nulliparity
3. late menarche
4. first pregnancy after age 30
86. A breast lesion which usually appears during lactation is
A
A. abscess
B. fibrocystic mastopathy
C. intraductal papilloma
D. Pagets disease of the nipple
E. sclerosing adenosis
87. A 45-year-old woman noted bleeding from her left nipple. A 2.5 cm subareolar mass was felt. Nipple bleeding
may occur in all of the following EXCEPT
E
A. intraductal carcinoma
B. intraductal papilloma
C. Pagets disease of the breast
D. papillary adenocarcinoma
88. All of the following appear to be risk factors in the development of breast carcinoma EXCEPT
A
A. early and frequent pregnancies
B. exposure of the breast to x-irradiation
C. having a mother and/or sister with breast cancer
D. high fat intake in the diet
E. menopausal or postmenopausal estrogen therapy
89. Each of the following constitutes a risk factor for breast cancer EXCEPT
D
A. heredity
B. fibrocystic disease
C. nulliparity
D. prolonged breast feeding
E. prior breast cancer
90. Which of the following breast lesions is typically benign?

A
A. cystosarcoma phyllodes
B. comedocarcinoma
C. lobular carcinoma
D. medullary carcinoma
E. intraductal carcinoma
91. Each of the following represents premalignant disease or a risk factor for breast cancer association
EXCEPT
B
A. proliferative fibrocystic changes
B. fibroadenoma
C. Pagets disease
D. lobular carcinoma in situ
E. atypical ductal hyperplasia
E
breast cancer
considered:
A
factors
progesterones

A
Questions 95-96
A. cystosarcoma phyllodes
B. Pagets disease
C. mild epithelial hyperplasia
D. lobular carcinoma-in-situ
E. Mondors disease
95. Considered a marker of increased risk for the development of subsequent invasive carcinoma
D
96. Usually presents as a large tumor

A
MICROBIOLOGY (#97-98 = 2)
97. Acute mastitis MOST commonly occurs at or during
D
A. birth
B. puberty
C. pregnancy
D. lactation
E. blunt trauma to the breast
98. The most common causative organism in breast abscess is
A
A. Staphylococcus aureus
B. Streptococcus pyogenes
C. Salmonella
D. Nisseria gonorrhea
E. Mycobacterium tuberculosis
DIAGNOSIS (#99 - 134 = 63)
99. Mammographic lesions that are strongly associated with malignancy include all of the following EXCEPT
A
A. large and coarse calcifications
B. thickened epidermis
C. poorly defined mass lesions
D. fine stippled calcifications
E. increased density
100. Which of the following studies is most effective in differentiating between solid and cystic lesions?
C
A. screening mammography
B. xeromammography
C. ultrasonography
D. thermography
101. A 31-year-old G1P1 female presents with a unilateral serosanguinous nipple discharge. She has no palpable
abnormalities on physical exam. The most likely diagnosis is
D
A. ductal carcinoma in situ
B. fibroadenoma
C. cystosarcoma phyllodes
D. intraductal papilloma
102. A 45-year-old patient presents with a tender breast lump of ten days duration. Her family history is negative
for breast cancer. Her last menstrual period ended 3 1/2 weeks ago, and todays mammogram exhibits no signs of
malignancy. All of the following are appropriate management options EXCEPT
B
A. reexamine her in 10 days
B. reassure her that this is just a premenstrual change and resume routine screening
C. obtain an ultrasound exam of the nodule
D. schedule her for an excisional biopsy
E. perform needle aspiration
103. Which of the following conditions LEAST warrants a breast biopsy for diagnosis?
B
A. an inverted nipple
B. bilateral green-colored nipple discharge
C. eczematous changes of the nipple
D. a nonpalpable mammographic abnormality
E. spontaneous unilateral single-duct nipple discharge
104. Which of the following statements regarding mammography are true?

A
1. Mammography now results in an absorbed dose of radiation of approximately 0.1 rad at
midbreast
2. Mammographic screening should be carried out annually for women after the age of 50 years
3. Women whose breast carcinomas were detected by mammography have had a higher disease-
free five-year survival rate than women whose cancers were found by palpation
4. A baseline mammographic examination should be obtained routinely for women before the
ages of 25 and 30 years
105. A 32-year-old woman complains of bloody discharge from the nipple. Physical examination reveals no breast
mass. The nipple itself is normal. The most likely diagnosis is
C
A. fibrocystic changes
B. fibroadenoma
C. intraductal papilloma
D. cystosarcoma phyllodes
106. Which one of the following is the standard imaging method for assessing breast disease?
E
A. sonography
B. diaphanography
C. thermography
D. nuclear magnetic resonance
E. mammography
107. All of the following conditions are indications for open breast biopsy EXCEPT
B
A. dominant mass throughout the menstrual cycle
B. multiple cystic masses
C. aspiration of bloody fluid
D. spontaneous serosanguinous discharge
E. suspicious mammogram
108. A 30-year-old woman was in an automobile accident in which her right breast struck the steering wheel.
Within a month, a 3-cm firm mass developed in the breast. The likeliest diagnosis is
C
A. abscess
B. carcinoma
C. fat necrosis
D. fibrous mastopathy
E. plasma cell mastitis
109. A 60-year-old woman had a firm, fixed 2 cm mass in her right breast. This is most likely
C
A. fibroadenoma
C. carcinoma
D. periductal mastitis
110. A 25-year-old woman felt a rubbery, movable 2 cm mass in her right breast. It was removed surgically. The
most likely diagnosis is
A
A. fibroadenoma
C. carcinoma
D. periductal mastitis
111. A 65-year-old woman had a hard, fixed 2 cm mass in her left breast. Clinically and on mammography it was
diagnosed as a carcinoma. The most common type of breast cancer is
A
A. infiltrating duct carcinoma with fibrosis
B. intraductal carcinoma
C. lobular carcinoma
D. medullary carcinoma
E. papillary carcinoma
112. Signs of breast cancer include each of the following EXCEPT

D
A. bloody nipple discharge
B. skin dimpling
C. Pagets disease of the nipple
D. breast discomfort
E. unilateral nipple retraction
113. In a 36-year-old woman with a painless hard dominant breast lump, the next step should be
B
A. mammography of the lump
B. fine needle aspiration cytology
C. radiation therapy
D. radical mastectomy
E. bone scan
114. Mammography should be employed

E
A. annually for asymptomatic women over age 30
B. to screen other areas of the breast in an 18-year-old found to have a fibroadenoma
C. every 6 months in 30-year-old women identified as high risk
D. to definitely characterized a dominant mass discovered on physical examination
E. no more frequently than annually in asymptomatic women 50 years of age or older
115. Stage I carcinoma of the breast is characterized by each of the following EXCEPT
B
A. tumor size smaller than 2 cm
B. two or more axillary lymph nodes are positive
C. no distant metastasis are present
D. five year survival is 85% or more
E. estrogen receptors may be positive or negative

A
C
A. breast abscess
B. breast cancer
C. fibroadenoma
E. phyllodes tumor
D
A. breast abscess
B. breast cancer
C. fibroadenoma
E. mastitis
B
A. breast abscess
B. breast cancer
C. fibroadenoma
120. A female patient presents with a tender breast mass with erythema over the skin. The primary clinical
diagnosis is:
A
A. breast abscess
B. breast cancer
C. fibroadenoma
D
A. mammography
B. ultrasound
C. CT scan
D. biopsy
E. MRI

E
Questions 123-127
For each of the following characteristics, select the type of benign breast disorder that is appropriate.
A. Fibrocystic changes
B. Fibroadenoma
C. Intraductal papilloma
D. Mammary duct ectasia
E. Galactocoele
123. Inspissated secretions

D
124. Cystic dilation of ducts
E
125. Abnormal nipple discharge
C
126. Hormonally related symptoms
A
127. Lesion may be up to 15 cm in size
B
Questions 128-129
A. T1N0M0
B. T1N1M0
C. T2N0M0
D. T2N1M0
128. Describes a 2.5-cm breast cancer with no evidence of regional or distant metastasis
C
129. Describes a breast cancer which presented with a 1-cm skin ulceration
E
Questions 130-134
A. Intraductal papilloma
B. Fibroadenoma
C. Breast abscess
D. Pagets disease
E. Infiltrating intraductal carcinoma
130. A 16-year-old is found to have firm mobile nodules in both left upper and right lower breast quadrants
B
131. The most common lethal condition of women in the prime of life
E
132. A 28-year-old woman who has breast pain and fever with onset during her second month of nursing
C
133. A benign condition that can give a bloody nipple discharge
A
134. A scaly nipple rash associated with underlying malignancy requiring further investigation
D
Questions 135-139
A. Fibrocystic changes
B. Tuberculosis of the breast
C. Mastitis
D. Breast abscess
E. Inflammatory breast cancer
135. 30 y.o. female with draining sinuses on one breast of one year duration. No definite breast mass,
just indurations. Positive ipsilateral axillary lymph nodes.
B
136. 40 y.o. female with erythema over one breast, tender, warm, with no definite mass.
C
137. 35 y.o. female with a breast mass, tender, with erythema, and warmth.
D
138. 50 y.o. female with no definite breast mass, but with erythema, no tenderness, no warmth, no
axillary nodes.
E
139. 45 y.o. female with nodular breast tissues, no definite breast mass, slightly tender, no erythema, no
warmth, no axillary nodes.
A
Questions 140-147
A. Breast cancer
B. Gynecomastia
C. Virginal hypertrophy or macromastia
D. Phyllodes tumor
E. Fibroadenoma
140. 15 y.o. male with enlargement of one breast, slightly tender, no erythema, no warmth, no axillary
nodes.
B
141. 45 y.o. male with enlargement of one breast, slightly tender, no erythema, no warmth, no axillary
nodes.
B
142. 45 y.o. male with hard mass, not fixed, no axillary nodes.
A
143. 40 y.o. female with one breast 3x the size of the other breast. No definite breast mass. No axillary
nodes.
C
144. 80 y.o. female with breast mass on one side with ill-defined border, no axillary nodes.
A
145. 40 y.o. female with 10cm multinodular breast mass on one side, movable but fixed to overlying
skin, no axillary nodes.
D
146. 35 y.o. female with well-defined , very movable mass, nontender, solid, no axillary nodes.
E
147. 30 y.o. female with fungating mass on one breast, no axillary nodes.
A
Questions 148-154
A. Macrocyst
B. Galactocoele
C. Pagets disease of the nipple
D. Intraductal papilloma
E. Breast cancer
148. 35 y.o. female with sanguinous nipple discharge on one breast. No palpable breast mass. No
axillary nodes.
D
149. 45 y.o. female with nipple-areolar erosions on one breast. No palpable breast mass. No axillary nodes.
C
150. 30 y.o. female with a breast mass on one side with an ipsilateral axillary lymph node.
E
151. 60 y.o. female with a breast mass on one side, depressible, no axillary nodes.
A
152. 30 y.o. female, lactating, with slightly tender breast mass noted recently, no erythema, no warmth,
no axillary node.
B
153. 55 y.o. female with bilateral breast masses, not fixed, slightly tender, no erythema, no warmth, no
axillary nodes.
A
154. 40 y.o. female with hard mass with ill-defined border, not fixed to underlying nor overlying
structures. No axillary nodes.
E
TREATMENT (#155 -190 = 36)
155. A 16-year-old girl undergoes a large-bore needle biopsy of a breast lump that shows cellular fibroadenoma.
What is the most appropriate course of action?
B
A. radiotherapy
B. local excision
C. radical mastectomy
D. modified radical mastectomy
E. no further therapy
156. A young woman presents with a small breast nodule, which on needle biopsy is found to be an
adenocarcinoma. Examination is otherwise unremarkable and laboratory studies including CA-15-3 level are
normal. Interventions likely to be curative include
A
1. radical mastectomy with full axillary dissection
2. lumpectomy with axillary sampling followed by radiotherapy
3. simple mastectomy without axillary dissection
4. pulse chemotherapy and hormonal therapy without additional local treatment
157. Correct statements about breast cancer include
A
1. premenopausal patients with stage I breast cancer may benefit from adjuvant chemotherapy
2. postmenopausal patients with hormone receptor-positive stage II breast cancer should receive
adjuvant tamoxifen therapy
3. patients with stage II breast cancer and extensive involvement of axillary lymph nodes may
benefit from dose-intensive chemotherapy with bone marrow transplantation
4. radiotherapy of the chest wall combined with axillary and supraclavicular ports is an
alternative adjuvant treatment
158. Adjuvant therapy is given to patients who no longer have detectable residual cancer following primary
resection of disease but who are considered to be at risk for recurrence. The largest group of patients who receive
adjuvant treatment are those with breast cancer. True statements regarding adjuvant treatment of breast cancer
include
A
1. disease-free survival is improved
2. overall survival may be improved
3. younger patients obtain more benefit from chemotherapy but patients over 50 do better
with hormonal treatment
4. many patients are cured by adjuvant treatment
159. The median survival of untreated patients with breast cancer is

C
A. 8 months
B. 1 1/2 years
C. 2 1/2 years
D. 5 years
E. not known
160. When stage I breast cancer is treated by partial mastectomy and axillary dissection, further therapy should
include
D
A. nothing
B. chemotherapy
C. antiestrogen agents
D. radiation of the affected breast
E. oophorectomy if premenopausal
161. A 62-year-old patient whose screening mammogram shows punctate microcalcifications should
D
A. undergo immediate mastectomy
B. undergo a biopsy of only palpable abnormalities
C. return for a repeat mammogram in one year
D. undergo a mammographically directed breast biopsy
E. have an ultrasound exam of the suspicious area
162. The most common site of early recurrent carcinoma is

B
A. the opposite breast
B. the skin of the chest wall
C. axillary lymph nodes
D. bone
E. lung
163. Which of the following lesions of the breast has the best prognosis?
D
A. infiltrating papillary carcinoma
B. infiltrating duct carcinoma with productive fibrosis
C. colloid carcinoma
D. tubular carcinoma
164. Which of the following statements concerning acute mastitis are true?
E
1. It occurs most often in nursing women
2. It is extremely painful
3. Staphylococcus aureus is the most common causative organism
4. surgical drainage is frequently required
165. A 38-year-old woman has had a painful cyst in her left breast for two weeks. Which of the following
statements concerning the mass are likely to be true?
A
1. If untreated, the cyst may grow to reach several centimeters in diameter
2. If it is aspirated, the cyst may reappear in one or two months
3. Unopposed estrogen stimulation may be an etiologic factor in the cyst
4. If it is completely aspirated but still palpable, the cyst should be observed for a month or two
166. Which of the following statements concerning reconstruction of the breast after mastectomy are true?
A
1. It may be done right after the mastectomy.
2. It may be done after a course of irradiation or chemotherapy
3. It may be done using the rectus abdominis myocutaneous flap
4. It may increase the chance of recurrent carcinoma
167. A 45-year-old woman presents with stage II breast carcinoma. Accepted methods of treatment would include
A
1. Modified radical mastectomy
2. Classical radical mastectomy
3. Total mastectomy with axillary dissection
4. Total mastectomy with radiation to the axilla
Questions 168-169
A 35-year-old woman undergoes a right total mastectomy and axillary node dissection for a 6.5-cm invasive ductal
carcinoma. There are 3 of 18 lymph nodes involved with tumor. Distant metastases are not present.
168. This patient has which stage of breast cancer?

D
A. Stage I
B. Stage IIA
C. Stage IIB
D. Stage IIIA
E. Stage IIIB
169. Estrogen and progesterone receptors are positive. The patient should be treated with
C
A. oophorectomy
B. tamoxifen
C. combination chemotherapy
D. aminoglutethimide and prednisone
E. radiation to the right chest and supraclavicular nodes
170. A multinodular mass from the lower inner quadrant of a 45-year-old womans breast is biopsied. The
pathologic diagnosis is cystosarcoma phyllodes. Which of the following surgical procedures should be performed?
E
A. classical radical mastectomy
B. modified radical mastectomy
C. lumpectomy
D. simple mastectomy
E. wide excision
171. The most important prognostic factor in the treatment of a malignant breast nodule is
C
A. age at diagnosis
B. size of tumor
C. axillary nodules
D. estrogen receptors on the tumor
E. progesterone receptors on the tumor
172. Estrogen receptor activity can be characterized by which of the following statements?
E
A. positive only in breast cancer
B. will react only in binding estrogen
C. is associated with a poor prognosis
D. is positive only in premenopausal women
E. is an indication for adjunctive endocrine therapy
173. Current adjunctive therapy for a premenopausal 40-year-old woman following radical mastectomy with a 2.5
cm ductal carcinoma with 2 of 15 lymph nodes involved and an estrogen receptor negative tumor includes
B
A. tamoxifen
B. cytotoxic chemotherapy
C. androgens
D. oophorectomy
E. pituitary irradiation

A
B. radiotherapy
E
palliation
radical mastectomy.
E
4. improve survival
A
B. big tumor size
recommendation is:
A
B. tamoxifen
recommendation is:
B
B. tamoxifen
180 Regarding follow-up and prognosis,
E
followup program
181. Consider each statements regarding tamoxifen. It

A
1. significantly improves recurrence free survival at ALL ages
2. reduces the incidence of contralateral breast cancer
3. can cause endometrial cancer
4. causes excessive weight gain

E
1. Radiotherapy after complete local excision reduces the risk of local recurrence.
2. Breast conservation surgery requires a complete local excision prior to radiotherapy.
3. There is no difference in the rate of survival or distant metastasis between women having
radical mastectomy.
183. The aims of follow-up consist of:

E
1. early detection of local recurrence
2. detection of treatment related toxicities
3. provision of psychosocial support
4. screening for a new primary breast cancer
184. Follow-up of breast cancer patients should be

E
1. cost-effective
2. symptom-directed
3. life time
4. convenient for the patient
185. Poor prognostic factors in breast cancer consists of:

E
1. ER negative tumors
2. Positive axillary nodal metastasis
3. Higher stage
4. Older age
Questions 186-190
A. Fine needle aspiration

B. Needle localization biopsy with specimen mammography
C. Combination chemotherapy
D. Simple mastectomy
E. Quadrant subtotal mastectomy
186. Treatment for non-palpable stippled calcification seen on screening mammogram

B
187. Appropriate therapy for a 92-year-old woman with congestive heart failure found to have an
ulcerating 6 cm left breast mass
D
188. Appropriate outpatient management of a patient with bilateral upper outer quadrant breast nodularity with one
nodule firmer and larger than the surrounding tissue
A
189. The best adjunctive treatment to be used following modified radical mastectomy for estrogen-receptor-
negative, poorly differentiating Stage II carcinoma in a premenopausal woman
C
190. The most frequent operation in recent years for treatment of Stage I breast cancer in premenopausal women
also treated by radiation therapy
E
ISSUES (#191 - 200 = 10)

E
E

A
194. One of your patients who has metastatic breast cancer develops shortness of breath. She presents to the
emergency department, where you diagnose pericarditis, which is confirmed by echocardiography. Soon after,
cardiac tamponade occurs and she develops ventricular tachycardia and then ventricular fibrillation.
Cardiopulmonary resuscitation is unsuccessful. Despite your request, her family refuses an autopsy. How should
you indicate the cause of death on the death certificate for this woman?
D
A. cardiopulmonary arrest due to ventricular fibrillation due to ventricular tachycardia
B. ventricular fibrillation due to cardiac tamponade due to pericarditis
C. pericarditis
D. breast cancer
E. the death certificate should not be filled out; this is a coroners case
195. Correct statements concerning breast-feeding include which of the following?

D
A. The incidence of infections is greater in breast-fed than in bottle-fed infants
B. Breast milk is frequently insufficient in quantity
C. Iron deficiency anemia is less frequent in infants fed cows milk
D. Significant quantities of immunoglobulins are provided by breast milk
196. All the following statements about the epidemiology of breast cancer in women are true EXCEPT
D
A. in the U.S., the cumulative lifetime probability of dying from breast cancer is about 4%
B. 70 to 80 percent of all breast cancers occur in patients without identifiable risk factors
C. the risk of developing breast cancer is highest for women over 75 years of age
D. first-degree relatives of patients with breast cancer have a tenfold increased risk of
developing breast cancer
E. the incidence of breast cancer is highest in affluent westernized countries
197. A familial aggregation pattern exists for cancer of all the following organs EXCEPT
D
A. breast
B. retina
C. colon
D. larynx
E. skin
198. The use of estrogen-containing oral contraceptives increases the risk of

D
A. breast cancer
B. vaginal cancer
C. osteoporosis
D. thromboembolism
199. Which of the following statements about the risks and benefits of postmenopausal hormonal replacement
therapy is true?
D
A. The increased risk of endometrial cancer is especially high among women using combination
preparations (estrogen and progestin)
B. The main potential benefit is a reduced risk of hip fracture
C. Most studies have shown a reduced risk of breast cancer among women using estrogen-only
preparations
D. Most studies have shown a beneficial effect on mortality from coronary heart disease
E. There is a slightly increased risk of pulmonary embolism
200. Use of postmenopausal estrogens has been consistently associated with

A
A. an increased risk of endometrial cancer
B. a decreased risk of breast cancer
C. an increased risk of osteoporotic fractures
D. an increased risk of coronary heart disease
E. an increased incidence of liver cancer
THE BREAST
HEALTH PROBLEM
BREAST DISORDER
FOLDER 7
DETAILS AND FORMAT

DETAILS AND FORMATS OF LEARNING AND EVALUATING ACTIVITIES
Content
NOTES ON
PRIMARY HEALTH CARE PHYSICIAN
PROBLEM-BASED LEARNING IN MEDICINE
GUIDELINES AND FORMAT ON
OVERVIEW AND PERSONAL PERSPECTIVE
PUBLIC HEALTH EDUCATION
COMMUNITY HEALTH MANAGEMENT
CASE PRESENTATION AND DISCUSSION
PSYCHOSOCIAL ISSUES
BIOETHICAL ISSUES
MEDICOLEGAL ISSUES
RESEARCH ISSUES
GLOSSARY
SELF-EVALUATION
PRESENTATION IN A SYMPOSIUM
PRIMARY HEALTH CARE PHYSICIAN
Primary Health Care Physician is a physician who practices primary health care.
Definition of Primary Health Care by WHO
Essential health care made universally available to individuals and families in the community by means
acceptable to them, through their full participation and at a cost that the community and country can afford.
Health care system and socioeconomic development
PHC forms an integral part both of the countrys health system of which it is the nucleus and of the overall
social and economic development of the community.
Features
Community participation
vs overdependence on medical doctors
Appropriate technology
vs high-cost and sophisticated technology
Intersectoral linkages
vs. reliance on the government sector or the medical doctor
Partnership Approach
1. active community participation and involvement

2. intersectoral collaboration
3. development and use of appropriate technology to meet local health needs
4. development of support mechanisms to sustain PHC implementation
Essential health care
1. information and education on health

2. proper nutrition
3. water and sanitation
4. maternal and child health
5. immunization
6. prevention and control of endemic diseases
7. treatment of common diseases
8. provision of essential drugs
Aspects of health care
PHC is concerned with the promotive, preventive, curative, palliative, and rehabilitative aspects of health
care.
VIIA
PROBLEM-BASED LEARNING IN MEDICINE
PBL in Medicine
- learning the science and art of medicine
in the functional or clinical context.
Format of PBL in Medicine in Small Group
Session I (2 hours)
1. Facilitator presents a problem (simulated or actual).
2. Students attempt to understand and solve the problem through brainstorming, discussion, and
consensus. They learn from each other as well as discover learning issues
(later converted to students' learning objectives).
3. Students decide on a learning plan with or without the help of the facilitator. The learning plan contain
the following:
Learning objectives
How to attain the learning objectives
Methods
Reading - what and which books, journals
Asking - who, where, when
Doing - what, where, when
Individual work or division of labor
How to assess attainment of learning objectives
Timetable
Independent Study (based on timetable in the learning plan)

Students implement learning plan.
Session II (2 hours)
1. Students report and discuss the learning gained during the independent study in trying to understand
and solve the initial problem.
2. Student may be given another problem to apply what they have just learned for reinforcement purposes.
3. Students are asked to assess their individual and group performance in the learning process.
4. Facilitator gives feedback on the individual and group learning process.

He may also give comments on the content of the learning objectives as well as on the
problem(s).
VIIB1
Practice and Learning of Medicine - The Process
1. An MD meets a patient without prior knowledge of what the patient's problem is.
2. During the encounter, the MD establishes rapport, diagnoses, treats, and gives
advices with the goal of resolution of the health problem of the patient.
3. In the process of understanding and resolving the patient's problem, the MD

invariably encounters some insecurities, questions, and gaps in competences.
4. The MD fills in the gaps in competences through various means, such as self-study
and learning from other people like consultations, referrals, and enrolling in
a formal course.
5. The new competences acquired are used by the MD on the patient on hand
and on future patients.
PBL in Medicine - The Process
1. The student is presented with a health problem which can be simulated or

actual, without the student having prior study on the problem.
There is no prior teacher's lecture nor prior assignment to study on the
problem.
2. The student tries to understand and to solve the problem.
3. In the process of trying to understand and to solve the problem, the student
will invariably encounter questions, uncertainties, and gaps in
competences, which constitute the so-called "learning issues."
4. The student then decides how to go about settling the "learning issues."
5. The student implements his plan of action.
6. The student applies what he learned to the problem on hand as well as to

future problems or patients.
VIIB2
Comparison of Lecture and Problem-based Learning
PBL
Lecture Individual/Small Group/Large Group
Retention
of learning + ++ ++ ++
Easy recall + ++ ++ ++
Problem-solving + ++ ++ ++
Critical thinking + ++ +++ +++
Communication x x + +
Interpersonal skills x x + +
Cooperative
learning x x + +
Self-directed
learning x + + +
Competences needed in conducting PBL
1. Proper understanding of whole process of PBL (knowledge).
2. Commitment to use PBL if educator believes it is an effective method in producing

competent physician (attitude).
3. Skills in facilitating learning (skills).
4. Skills in group dynamics (skills).
VIIB3
GUIDELINES AND FORMAT
ON
OVERVIEW AND PERSONAL PERSPECTIVE
Health Information and Ideas Sharing and Exchange needed for the following topics:
Overview and Personal Perspective on the Breast Disorders (In general)
Overview and Personal Perspective on the Breast Cancer
Tasks
To write a paper containing
1. an overview of the Breast Disorders in general and Breast Cancer in particular and
2. a personal perspective on how to solve them in ones community.
Format
Overview and Personal Perspective on the Breast Disorders
(Name and Title of Contributor)
I. Concept of Breast Disorders

A. Definition of Breast Disorders
B. Effect of Breast Disorders on the health of the individual, family, and community
II. Common types of Breast Disorders (from general to specific)
III. Common causes of Breast Disorders (from general to specific)
IV. Magnitude of the Breast Disorders

Global National Local
N.A./Europe/Australia/Africa/Asia
Incidence Rate
in #/100,000
Mortality Rate
Morbidity Data
( include
quality of life)
* Give the sources of data
IV. Personal perspective on the possible solutions to the Breast Disorders in the community
*Describe a community health management program which you think can solve Breast Disorders. You can utilize
existing programs or you can create your own. Use the following format:
1. Goal /objective:
2. Strategies and Programs:
Note: Utilize the concept of primary health care
Community participation: People
Intersectoral linkages: NGO, Government, Health Care Providers
3. Evaluation Indicators:
V. References
VIIC1
Format
Overview and Personal Perspective on the Breast Cancer Health Problem
I. Concept of Breast Cancer Health Problem

A. Definition of Breast Cancer Health Problem
B. Effect of Breast Cancer Health Problem on the health of the individual, family, and
community
II. Common types of Breast Cancer Health Problem (from general to specific)
III. Common causes of Breast Cancer Health Problem (from general to specific)
IV. Magnitude of the Breast Cancer Health Problem

Global National Local
N.A./Europe/Australia/Africa/Asia
Incidence Rate
in #/100,000
Mortality Rate
Morbidity Data
( include
quality of life)
* Give the sources of data
IV. Personal perspective on the possible solutions to the Breast Cancer Health Problem in the community
*Describe a community health management program which you think can solve Breast Cancer Health Problem.
You can utilize existing programs or you can create your own. Use the following format:
1. Goal /objective:
2. Strategies and Programs:
Note: Utilize the concept of primary health care
3. Evaluation Indicators:
V. References
Criteria to be used for evaluation

Clear
Adequate in terms of content
Concept of the health problem
Common types of the health problem
Common causes of the health problem
Magnitude of the health problem in the global, national, and local levels
Personal perspective on possible solution of the health problem using a
primary health care approach
Format followed
Presence of references
Within the prescribed length (not more than 10 pages of short bond papers, double-spaced)
VIIC2
ON
PUBLIC HEALTH EDUCATION
Health Information and Ideas Sharing and Exchange needed for the following topics:
Public Health Education on
Prevention of Mastitis
Early Detection of Breast Cancer
Tasks
1. To design a public health education on prevention of mastitis and early detection of breast
cancer.
2. To write the script and content of the public health education.
Format
A Public Health Education
on
Prevention of Mastitis
(Early Detection of Breast Cancer)

I. Educational Design
1. Specify the target learners
A large or small group of nonmedical audience
Public
Organizations/Clubs
Mothers Class
Barangay Council
Parent-Teacher Association
Rotary/Lions/Jaycees Clubs
Others
2. Specify the physical environment of the education
Classroom set-up
Nonclassroom set-up
3. Specify the media to be used
Nonprint
Face-to-face
Radio
Television
Internet
Print
Newspaper
Health Magazine
4. Formulate the learning objectives
5. Outline the content
6. Specify the teaching-learning strategies
7. Specify the evaluation methods
II. Script and Content of the Health Education
III. References of content

VIID1
Criteria to be used for evaluation
Clear
Description of the problem
Importance of the problem
Preventive measures
Early detection measures
Format followed
VIID2
ON
COMMUNITY HEALTH MANAGEMENT
Health Information and Ideas Sharing and Exchange needed for the following topic:
Breast Cancer Control Program in the Community
Task
To design a community health plan using a primary health care approach to solve
the Breast Cancer Health Problem.
Format
A Community Health Plan
on
Breast Cancer Control Program
I. Describe the community and the selected health problem.
II. State the goal and objectives of the community health plan.
III. Formulate strategies and programs utilizing the concept of primary health care
IV. Formulate evaluation methods and indicators.
V. Cite references.
Criteria to be used in evaluation

Clear
Problem identification
Objectives
Strategies
Evaluation methods and parameters
Format followed
VIIE
ON
CASE PRESENTATION AND DISCUSSION
Health Information and Ideas Sharing and Exchange needed for the following cases:
Fibroadenoma of the Breast

Breast Cancer
Fibrocystic Changes of the Breast
Mastitis
Tasks
1. To present through a brief and concise write-up of the clinical data of an
actual patient with a breast disorder and then
2. To discuss the clinical management issues.
Format
Case Presentation and Discussion
on
Fibroadenoma
(Breast Cancer, Fibrocystic Changes, Mastitis)
Case Presentation
Present Database
General Data
Minimum: Initials of patient, age, sex
As needed: Occupation, residence, religion
Chief Complaint
History of Present Illness/Condition
As needed:
Past Medical History
Personal Social History
Obstetrical and Gynecological History
Physical Examination
Case Discussion
Must include the following 4 parts:
I. Clinical Diagnosis
II. Paraclinical Diagnostic Procedures
III. Treatment
IV. Prevention and Health Promotion
VIIF1
I. Clinical Diagnosis
1. Identify data from database which can serve as cues for a clinical diagnosis.
Age/Sex
Symptoms
Signs
2. Based on pattern recognition and prevalence, decide on the primary and

secondary diagnoses. Primary diagnosis is what you think is the most likely
diagnosis and secondary diagnosis is the closest second.
Primary Clinical Diagnosis:
Secondary Clinical Diagnosis:
3. Illustrate/explain how you arrive to the primary and secondary clinical

diagnoses.
Use the clinical diagnostic processes of pattern recognition and prevalence.
Use algorithm as much as possible.
Use pathophysiology to support your primary and secondary clinical
diagnoses.
II. Paraclinical Diagnostic Procedures
1. Restate your primary and secondary clinical diagnosis.

2. Decide on whether you need a paraclinical diagnostic procedure or not.
If YES, why? If NO, why?
Use the processes of certainty and proposed treatment of your

primary and secondary diagnoses as basis.
Certainty* Treatment Modality

Primary Diagnosis
Secondary Diagnosis
*Place figures such as 10%, 50%, 70% certain and basis of

certainty, whether based on signs, symptoms, and
prevalence or just on symptoms and prevalence or
just prevalence.
**If you decide you dont need a paraclinical diagnostic procedure,

proceed to TREATMENT.
3. If you decide to go for a paraclinical diagnostic procedure, select one from at

least two procedures that may be done.
Use the following table:

Diagnostic
Procedure 1
Diagnostic
Procedure 2
VIIF2
4. After selecting one paraclinical diagnostic procedure, briefly describe how it is
done and what will be the result that will firm up your diagnosis.
5. Present the paraclinical diagnostic procedure(s) that were done on the patient
starting with the one that you are recommending. Then, interpret the
results.
III. Treatment
1. State your pretreatment diagnosis - both primary and secondary.

2. State the goals of treatment for the primary diagnosis.
3. Decide on the treatment modality.
Nonoperative
Operative
4. Decide how you evaluate the result or outcome of your proposed treatment.
5. If data are available, present the treatment procedures done on the patient and
their outcome.
IV. Prevention and Health Promotion
1. State your final diagnosis.

2. Briefly describe how you will advice patient on prevention of the disease and
health promotion.
Use pathophysiology.
Advice on screening.
Advice on early detection.
V. References

Clear
Management goals
Rapport
Clinical diagnostic process
Paraclinical diagnostic process
Treatment process
Indication for referral
Advice
Health promotion and maintenance
Format followed
VIIF3
ON
Format
Trigger 1
Patient with complaint of The Health Problem (Chief Complaint)
Questions:
1. What is The Health Problem?
2. What are the possible causes of The Health Problem?

___________________ __________________________ _____________________

___________________ __________________________ _____________________
___________________ __________________________ _____________________
condition causing the health problem?

More common __________________________ _____________________
__________________________ _____________________
Least common __________________________ _____________________
__________________________ _____________________
leading to the health problem.
VIIG1
The Health Problem
Trigger 2
Pertinent history
Age, sex / Chief complaint / When noted / Associated symptoms
Questions:

prevalence.
Primary diagnosis
Secondary diagnosis
diagnoses?

Demonstrate use of
3. others
Option 1
Option 2
Option 3

diagnosis?
VIIG2
The Health Problem
Trigger 3.
A paraclinical diagnostic procedure was done.
A ___________________________________ was done.

[Here is the picture/reading/result of the paraclinical diagnostic procedure.]
diagnosis? Why?
prevalence.
Primary diagnosis
Secondary diagnosis

If yes, how?
History?
Physical exam?

Nonoperative
Operative
VIIG3
The Health Problem
Trigger 4

____________________________________________
Questions:
The Health Problem
Trigger 5
A case write-up of a patient with a complaint of The Health Problem.
DIAGNOSIS IS NOT SPELLED OUT!

Signs and symptoms
Course in the management
Paraclinical diagnostic procedures done
Treatment
Outcome
Questions:
prevalence
Clear
Data for the triggers
Answers to the questions
Format followed
VIIG4
ON
PSYCHOSOCIAL ISSUES
Health Information and Ideas Sharing and Exchange needed for:
Psychosocial Issues in Patients with Breast Disorders
Tasks
To present and discuss psychosocial issues in patients with Breast Disorders.
Format
I. Present scenarios or cases.
II. Identify the psychosocial or behavioral issues.

Factors that promote disease
Factors that affect recovery
III. Explain how the psychosocial or behavioral issues affect health, disease, and recovery.
IV. Describe ways on how to modify behaviors or psychosocial issues so as to prevent disease and promote
health and recovery.
V. Cite references.
Clear
Scenarios or cases
Identification of a psychosocial issue
Influence on health and disease and recovery
Prevention and promotion
Format followed
VIIH
ON
BIOETHICAL ISSUES
Bioethical Issues in Patients with Breast Disorders
Tasks
To present and discuss bioethical issues in patients with Breast Disorders.
Format
II. Identify the bioethical issues.

Medical problems and practices that have moral issues
III. Describe the pros and cons of the bioethical issues.
IV. Make your stand on the issue and give a brief explanation.
V. Cite references.
Clear
Scenarios or cases
Identification of bioethical issue/s
Pros and cons
Decision-making
Format followed
VII-I
ON
MEDICOLEGAL ISSUES
Health Information and Ideas Sharing and Exchange Needed for:
Medicolegal Issues in Patients with Breast Disorders
Tasks
To present and discuss medicolegal issues in patients with Breast Disorders.
Format
II. Identify the medicolegal issues.

Physicians legal responsibilities and liabilities
III. Analyze the medicolegal issues.
IV. Suggest ways on how to solve medicolegal complications.
V. Suggest ways on how to prevent medicolegal complications.
VI. Cite references.
Clear
Scenarios or cases
Identification of medicolegal issue/s
Analysis of issues
Prevention and solution
Format followed
Within the prescribed length (not more than 10 pages of short bond paper, double-spaced)
VII-J
ON
RESEARCH ISSUES
Health Information and Ideas Sharing and Exchange Needed for:
Research Issues in Patients with Breast Disorders
Tasks
To present and discuss research issues in patients with Breast Disorders.
Format
II. Identify the research issues.
III. Explain the importance of the research issues.
IV. Present a brief research methodology on the identified issues.
V. Cite references.
Clear
Scenarios or cases
Identification of research issue/s
Importance of issues
Present a research protocol on the identified issues
Format followed
VIIK
ON
GLOSSARY
Glossary for Breast Disorders
Tasks
To write a glossary for Breast Disorders that will be useful for the general public.
Format
Glossary for Breast Disorders
Terms arranged alphabetically - definitions
References
Clear
Format followed
Within the prescribed length (25 - 50 terms)
VII-L
ON
SELF-EVALUATION
Self-evaluation for the General Public on Breast Disorders

Self-evaluation for the Health Care Providers on Breast Disorders
Tasks
1. To formulate examination questions and answer key to be used by the general public to sefl-
assess learning in Breast Disorders.
2. To formulate examination questions and answer key to be used by the health care providers to
self-assess learning in Breast Disorders.
Format
Self-Evaluation in Breast Disorders for the General Public
I. State the expected competencies.
II. Construct test questions at least two for each of the expected competencies.
Type of test questions:

Objective questions
True or false
Choose one best answer
Matching type
Multiple response questions
Problem-solving questions
Individual health management problem
Community health management problem
III. Provide an answer key.
IV. Include references.
VIIM1
Self-Evaluation in Breast Disorders for the Health Care Providers
I. State the expected competencies.
II. Construct test questions at least two for each of the expected competencies.
Type of test questions:

Objective questions
True or false
Choose one best answer
Matching type
Multiple response questions
Problem-solving questions
Individual health management problem
Community health management problem
III. Provide an answer key.
IV. Include references.
Clear
At least 2 per expected competency
Format followed
Within the prescribed length (25 -50 questions)
VIIM2
PRESENTATION IN A SYMPOSIUM
1. The symposium is a practical examination that will evaluate the following competences expected of a
primary health care physician:
Physician- Community Health Problem Solver

Wholistic Physician-Clinician
Physician-Researcher
Physician-Educator
Physician-Learner
Physician- Manager
During the symposium, the students are expected to demonstrate the above competences.
2. The students shall present the following symposium at the end of the course:
Symposium on Breast Disorders/Cancer as a Health Problem
Overview and Personal Perspective on Breast Disorders as a Health Problem

Overview and Personal Perspective on Breast Cancer as a Health Problem
Public Health Education on Prevention of Mastitis
Public Health Education on Early Detection of Breast Cancer
Community Health Management - Breast Cancer Control Program
Breast Lump
Breast Pain
Issues
3. Expectations, format, and evaluation criteria - See Evaluation Form.
4. A written report on the assigned topics in the symposium should be submitted on the last day of the
course.
5. Evaluation criteria of written reports consist of the following:

Clear
Format followed
VIIN1
Presentation in a Symposium
Evaluation Form
Student: Group No:
Overview and Personal Perspective on Breast Disorders as a Health Problem
Expectation: Within 5 minutes, the student is expected to present an Overview and Personal Perspective on
Breast Disorders as a Health Problem using a prescribed format.
Evaluation Criteria:
YES NO E S F US FINAL GRADE
E S F US
Clear
Concept of Breast Disorders
Common types of Breast Disorders
Common causes of Breast Disorders
Magnitude of the Breast Disorders in the
global, national, and local levels
Personal perspective on possible solution
of the Breast Disorders using a
primary health care approach
Format followed
Presented within the allotted time
Student: Group:
Overview and Personal Perspective on Breast Cancer as a Health Problem
Expectation: Within 5 minutes, the student is expected to present an Overview and Personal Perspective
on Breast Cancer as a Health Problem using a prescribed format.
E S F US
Clear
Concept of breast cancer
Common types of breast cancer
Common causes of breast cancer
Magnitude of the breast cancer problem
in the global, national, and local
levels
Personal perspective on possible solution
of the breast cancer problem
using a primary health care
approach
Format followed
Legend: E - Excellent
S - Satisfactory
F - Fair
US - Unsatisfactory
VIIN2
Evaluation Form
Student: Group:
Public Health Education on Prevention of Mastitis
Expectation: Within 5 minutes, the student/s is/are expected to present a Public Health Education on
Prevention of Mastitis using a prescribed format.
E S F US
Clear
Preventive measures
Format followed
Student: Group:
Public Health Education on Early Detection and Prevention of Breast Cancer
Expectation: Within 5 minutes, the student/s is/are expected to present a Public Health Education on
Early Detection of Breast Cancer using a prescribed format.
E S F US
Clear
Preventive measures
Format followed
S - Satisfactory
F - Fair
US - Unsatisfactory
VIIN3
Evaluation Form
Student: Group:
Community Health Management - Breast Cancer Control Program
Expectation: Within 5 minutes, the student/s is/are expected to present a
Breast Cancer Control Program using a prescribed format.
E S F US
Clear
Problem identification
Objectives
Strategies
Evaluation parameters
Format followed
Student: Group:
Breast Lump
Expectation: Within 10 minutes, the student/s is/are expected to present and discuss a patient with a chief
complaint of a breast lump using a prescribed format.
E S F US
Clear
Management goals
Rapport
Treatment process
Advice
Format followed
S - Satisfactory
F - Fair
US - Unsatisfactory
VIIN4
Evaluation Form
Student: Group:
Breast Pain
Expectation: Within 5 minutes, the student/s is/are expected to present and discuss a patient with a chief
complaint of breast pain using a prescribed format.
E S F US
Clear
Management goals
Rapport
Treatment process
Advice
Format followed
Student: Group:
Expectation: Within 5 minutes, the student/s is/are expected to present a discussion of psychosocial
issue/s in patients with Breast Disorders using a prescribed format.
E S F US Clear
Scenarios or cases
Identification of a psychosocial issue
Influence on health and disease and recovery
Prevention and promotion
Format followed
S - Satisfactory
F - Fair
US - Unsatisfactory
VIIN5
Evaluation Form
Student: Group:
Expectation: Within 5 minutes, the student/s is/are expected to present a discussion of bioethical issue/s
in patients with Breast Disorders using a prescribed format.
E S F US
Clear
Scenarios or cases
Identification of bioethical issue/s
Pros and cons
Decision-making
Format followed
Presence of References
Student: Group:
Expectation: Within 5 minutes, the student/s is/are expected to present a discussion of medicolegal issue/s
in patients with Breast Disorders using a prescribed format.
E S F US
Clear
Scenarios or cases
Identification of medicolegal issue/s
Analysis of issues
Prevention and solution
Format followed
Presence of References
S - Satisfactory
F - Fair
US - Unsatisfactory
VIIN6
Evaluation Form
Student: Group:
Expectation: Within 5 minutes, the student/s is/are expected to present a research protocol on identified
issue/s in patients with Breast Disorders using a prescribed format.
E S F US
Clear
Scenarios or cases
Identification of research issue/s
Importance of issues
Present a research protocol on the
identified issues
Format followed
Presented within the time allotted
S - Satisfactory
F - Fair
US - Unsatisfactory
Evaluator:
Date:
VIIN7

Breast Health Problem Course Pack - ROJoson

Enviado por

Dados do documento

Direitos autorais

Formatos disponíveis

Compartilhar este documento

Compartilhar ou incorporar documento

Opções de compartilhamento

Você considera este documento útil?

Este conteúdo é inapropriado?

Direitos autorais:

Formatos disponíveis

Breast Health Problem Course Pack - ROJoson

Enviado por

Direitos autorais:

Formatos disponíveis

THE BREAST

AN INSTRUCTIONAL PROGRAM FOR

PRIMARY HEALTH CARE PHYSICIANS

Reynaldo O. Joson, MD, MHPEd, MS Surg

About the Author ............................................................................................................. B

The Course Pack - Content and How to Use ...................................................................... D

Folder 1: Instructional Design ........................................................................................... I

Backgrounder of Design for University of the Philippines College of Medicine .... IA

Folder 2: Hypothetical and Actual Patient Management ..................................................... II

Patient with a Breast Lump ................................................................................... IIA

Folder 3: Problem-based Learning Issues - Form ................................................................ III

Folder 4: Learning Objectives ............................................................................................ IV

General Learning Objectives ................................................................................ IVA

Folder 5: Learning Resource Materials and References ..................................................... V

List of Recommended References ........................................................................ VA

Learning Resource Materials

The Breast Health Problem-Breast Disorders

Folder 6: Evaluation ......................................................................................................... VI

Folder 7: Details and Format ............................................................................................ VII

Primary Health Care Physician ............................................................. VIIA

Guidelines and Format

About the Author

Present Academic Positions

Education for Health Development in the Philippines

Dr. Reynaldo O. Josons email address is rjoson@pacific.net.ph

R.O. Josons Website (started in 1999)

Theme: Education for Health Development in the Philippines

Welcome to a learning experience in becoming a health professional.

1. I am treating you as an adult learner which

3. Active learning strategies and activities will be utilized as much as possible.

Reynaldo O. Joson, MD, MHPEd, MHA, MS Surg

The Course Pack

Folder 1: Instructional Design

Folder 1: Instructional Design

Folder 2: Hypothetical and Actual Patient Management

Folder 3: Problem-based Learning Issues

Folder 4: Learning Objectives

Folder 5: Learning Resource Materials

Folder 7: Details and Formats

The Course Pack

Start by reading Folder 1 on Instructional Design.

For details on specific learning and evaluating activities encountered in Folder 1,

Then, scan the rest of the Folders (2-7).

This consists of the study and learning proper.

Start with the

Then tackle the Pretest examinations.

Reynaldo O. Joson, MD, MHPEd, MHA, MS Surg

An Instructional Design on Breast Disorders

Classroom Learning Clinic Learning

Year IV 2 hours 2 hours preceptorial

Year V 2 hours Patient exposure

Year VII- Patient exposure

The big question is:

The breast problem consists primarily of three types:

1. Write an overview and a personal perspective on BREAST DISORDERS

2. Manage any patient with a BREAST DISORDER.

2.1 Demonstrate skills in:

2.2 Demonstrate qualities of an effective, efficient, and humane

2.3 Discuss/explain the biological foundation and basis of the

3. Discuss the following issues in a patient with a BREAST DISORDER.

4. Conduct a public health education on:

5. Conduct a research activity on BREAST DISORDERS.

6. Formulate a community health plan on the BREAST CANCER

7. Pass an examination on the BREAST DISORDER.

_ _____